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LIBRARY 

THE  UNIVERSITY 
OF  CALIFORNIA 

SANTA  BARBARA 


PRESENTED  BY 

DONALD  BEEKS 


73 


aJl^ 


Uibrary  of 
ISnbprt  Jlau^ian  BttU 


DEMENTIA    PRAECOX 


A  MONOGRAPH 


BY 


ADOLF  MEYER,  M.D. 

SMITH  ELY  JELLIFFE,  M.D. 

AUGUST  HOCH,  M.D. 


BOSTON 

RICHARD  G.  BADGER 

THE  GORHAM  PRESS 

1911 


lie.  i:^l2.c/^l 


Copyright,  1911,  by  Richard  G.  Badter 


AU  Rights  Reserved 


The  papers  forming  this  volume  formed  the 
Symposium  on  Dementia  Praecox  read  at  the 
meeting  of  the  American  Neurological  Associa- 
tion, held  at  Washington  in  May,  1910.  The 
paper  by  Dr.  Jelliffe  is  reprinted  from  The 
Journal  of  Mental  and  Nervous  Disease 
and  the  papers  by  Dr.  Meyer  and  Dr.  Hoch 
are  reprinted  from  The  Journal  of  Abnormal 
Psychology 


The  Gorham  Press,  Boston,  U.S.A.. 


CONTENTS 

I 

The  Nature  and  Conception  of  Dementia  Praecox  .    .    $ 

II 

Predementia  Praecox:  the  Hereditary  and  Con- 
stitutional Features  of  the  Dementia  Praecox 
Makeup ig 

III 

On    Some    Mental    Mechanisms    in    Dementia 

Praecox $1 


THE  NATURE  AND  CONCEPTION  OF 
DEMENTIA  PR.ECOX 


Digitized  by  the  Internet  Archive 

in  2007  with  funding  from 

IVIicrosoft  Corporation 


http://www.archive.org/details/dementiapraecoxOOmeyeiala 


THE  NATURE  AND  CONCEPTION  OF  DEMENTIA 

PRECOX* 

BY    ADOLF    MEYER,  M.D. 

Johns  Hopkins  University 

FROM  time  immemorial  medicine  has  arranged  its  facts 
under  as  small  a  number  of  names  designating  that 
which  struck  the  teachers  of  the  day  as  essentials. 
These  names  or  diseases  had  remained  descriptive  and  tradi- 
tional till  Kahlbaum  tried  to  get  more  definite  nosological 
principles  into  them  in  1863,  without  attaining  success,  on 
accountof  his  heavy  terminology.  At  the  same  time  the  old 
Graeco-Roman  names  were  liberally  readjusted  by  others, — 
Wahnsinn,  paranoia,  amentia,  had  been  added  by  German 
and  Austrian  writers,  and  when  Kraepelin  started  on  his 
great  nosological  revolution,  he  found  a  much  richer  and 
far  more  accurately  subdivided  material  in  German  psy- 
chiatry than  was  found  in  the  Anglo-American  contem- 
poraries. Indeed  Krseplin  found  the  new  types  too  many, 
too  one-sidedly  symptomatic,  or  too  exclusively  etiolog- 
ical, f  His  aim  still  was  the  formulation  of  types,  but  types 
representing  real  diseases,    f 

Kraepelin  bends  the  facts  of  psychiatric  observation 
to  the  concept  of  disease  processes.  \  His  psychiatry  works 
with  the  postulate  that  each  case  presents  one  of  a  relatively 
small  number  of  disease  entities  with  definite  cause,  course, 
and  outcome.  According  to  him,  the  assumption  of  transi- 
tion forms  is  merely  an  admission  of  nosological  cowardice. 
Each  disease  has  its  specific  lesion;  and  a  true  clinical  entity 
has  its  unity  of  cause,  course,  and  outcome,  and  is  necessa- 
rily the  clinical  picture  of  a  unitary  and  specific  histological 
process  or  condition  (Nissl),  with  general  paralysis  as  the 
p^ar^^igma;. 

This  is  the  bald  expression  of  the  dogma,  impiessive  and 
simple,  but  not  altogether  convincing  or  satisfying,  espe- 
cially when  we  come  to  his  large  group  of  dementia  praecox. 

The  various  lesions  found  in  dementia  prcecox  are  not 
clearly  understood   and   reduced   to   a   definite   intelligible 


8  Dementia  Praecox 

mechanism,  except  they  are  essentially  degenerative  or 
simple  reactive  processes.  With  general  paralysis  we  have  a 
definite  initial  factor,  the  syphilis,  and  a  very  specific  histo- 
logical reaction.  In  dementia  prcecox  the  cause  is  left  hope- 
lessly vague  by  Krsepelin;  the  course  is  decidedly  less 
fixed  than  that  of  general  paralysis,  and  the  symptomatology 
in  its  first  formulation  in  1895,  and  later,  emphasized  too 
many  things  which  prevail  also  in  other  conditions,  so  that 
altogether  too  many  errors  occurred.  In  four  hundred  and 
sixty-eight  of  Krsepelin's  Munich  diagnoses  even  between 
1904  and  1906,  28.8  per  cent  were  cases  subsequently  consid- 
ered to  be  manic-depressive  (Zendig)  —  altogether  too  broad 
a  margin  of  uncertainty.  Since  the  pendulum  has  swung 
towards  the  diagnosis  of  manic-depressive  insanity,  we  see 
again,  even  according  to  Alzeheimer,  cases  of  manic-depres- 
sive insanity  which  do  not  wholly  escape  a  certain  kind  of 
deterioration,  and  we  stand  in  this  respect  about  where 
the  vanguard  of  European  psychiatry  stood  just  before  the 
great  proclamation  of  Kraepelin's  nosology.  The  manias 
and  melancholias  in  the  very  narrow  sense  of  Meynert  and 
Ziehen  and  Wernicke  and  Mendel,  recovered  from  the  indi- 
vidual attack  in  about  ninety  per  cent  of  the  cases,  some 
remained  chronic,  a  few  became  paranoic,  and  a  few  deterio- 
rated. The  German  writers  had  considered  it  possible  to 
single  out  these  favorable  types  not  only  from  the  chronic 
manias  and  circular  cases,  but  also  from  the  less  simple  dis- 
ease forms  called  Wahnsinn  and  amentia,  which  had  a  larger 
percentage  that  was  apt  to  do  badly,  and  thus  included  far 
more  deteriorative  disorders.  Kraepelin's  inspiration  was 
the  Introduction  of  prognostic  principles,  and  the  recognition 
that  if  you  wanted  to  speak  of  a  disease  entity  you  had  to 
make  much  broader  units  —  large  enough,  by  the  way,  to 
make  the  refractory  cases  amount  to  a  lesser  percentage. 
The  greatest  gain  among  the  manic-depressive  psychoses, 
optimistically  called  recoverable,  or  at  least  non-deterio- 
rating, was  the  recognition  of  "mixed  forms."  His  other  gain 
was  the  insistence  on  the  fact  that  the  bulk  of  the  cases 
with  deterioration  in  the  so-called  functional  psychoses  had 
a  common  stamp  and  course  and  evolution,  an  assurance 
which  was  perhaps  too  readily  accepted,  as  happens  with 


The  Nature  and  Conception  of  Dementia  Praecox      9 

cases  whom  one  does  not  study  eagerly  because  they  seem 
doomed  to  permanent  custodial  care.  That  deteriorations 
and  even  cases  which  might,  or  might  not  deteriorate,  were 
all  one  disease  and  the  deterioration  not  merely  the  possibly 
inevitable  feature  of  human  makeup  and  mental  decline 
under  special  constellations,  was  but  a  short  step  further. 
What  is  or  was  Kraepelin's  dementia  praecox."*  The 
rare  dementia  paranoides  of  Kraepelin's  Fourth  Edition  had 
suddenly  been  enormously  enlarged  by  the  absorption  of 
almost  all  those  paranoic  states  which  showed  evidence  of 
dissociations  (hallucinations,  etc.);  Kahlbaum's  catatonia 
was  liberally  extended  so  as  to  include  everything  that 
showed  catalepsy,  negativism,  automatism,  stereotypy,  and 
verbigeration,  and  the  cases  of  silliness,  mannerisms,  and 
scattering  were  the  enlarged  hebephrenic  group.  The 
whole  group  was  transferred  from  the  degenerative  psy- 
chose  to  a  semi-exogenous  group.  Enumeration  of  phy- 
sical symptoms  led  to  ^the  "captivating  comparisons  with 
general  paralysis,  which  become  less  and  less  impressive, 
since  the  ingenious  vagueness  of  the  concept  of  general  par- 
alysis of  Kraepelin's  Fifth  Edition  has  been  swept  away 
through  the  method  of  Wassermann,  Plaut,  and  others. 
-The  claim  that  manic-depressive  insanity  occurs  only  on 
degenerative  basis,  and  that__th|s  degenerative  character 
was  lacking  in  dementia  praecox  was  based  on  the  claim 
THat  heredity  figu  redirTbril^'TeiTenty  per  cent  of  the  dementia 
praecox,  and  in  eighty  per  cent  of  the  manic-depressive  cases, 
and  it  was  often  said  that  any  one  can  develop  dementia 
prsecox,  as  well  as  any  one  can  develop  myxoedema.  The 
anatomical  lesions,  too,  failed  to  give  a  leading  clue.  In  short, 
there  was  beside  the  most  admirable  assertion  of  a  live  and 
fruitful  standpoint,  too  much  wandering  in  uncontrollable 
domains,  undoubtedly  at  the  expense  of  an  undesirable 
suppression  of  very  valuable  psycho-biological  facts.  Wil- 
mans's  paper  was  a  first  and  most  valuable  note  of  warning 
from  the  Kraepellnian  camp,  showing  diagnostic  pitfalls, 
but  quite  recently  Alzheimer  re-emphasized  the  adherence 
to  nosological  orthodoxy,  by  grouping  dementia  praecox  with 
the  essentially  organic  diseases,  and  not  merely  as  what  I 
would  call  an  incidentally  organic  disease. 


10  Dementia  Praecox 

With  all  these  strictures,  few  of  us  would  deny  to-day 
the  great  value  of  the  generalization  which  underlies  the 
entity  dementia  prsecox.  Yet,  while  others  searched  for 
pathognomic  signs  in  the  handshake,  the  reaction  to  pin- 
pricks and  the  like,  we  made  efforts  to  penetrate  into  the 
factors  at  work,  into  a  dynamic  interpretation.  My  main 
assertion  has,  however,  been  the  fundamental  importance  of 
the  psychogenic  material,  and  a  refusal  of  hard  and  fast 
nosological  doctrines.  In  the  Psych.  Bulletin,  1908, 
Vol.  5,  p.  257,  I  briefly  characterized  the  group  as  presenting 
essentially  substitutive  reactions,  the  types  of  defect  and  de- 
terioration of  which  show:  "Existence  or  development  of 
fundamental  discrepancies  between  thought  and  reaction, 
defects  of  interest  and  aifectivity  with  oddities;  dreamy 
fantastic  (crazy),  or  hysteroid  or  psychasthenold  reaction, 
with  a  feeling  of  being  forced,  of  peculiar  unnatural  inter- 
ference with  thought,  etc.,  frequently  with  paranoid,  cata- 
tonic, or  scattered  tantrums  or  episodes."  I  further  advo- 
cated that  it  was  possible  to  formulate  the  main  facts  of 
most  cases  in  terms  of  a  natural  chain  of  cause  and  effect, 
utilizing  the  psychobiological  material  at  hand,  better  than 
a  dogmatic  assumption  of  a  specific  but  hy^Otligtical  unitary 
toxic  principle. 

To  assure  common  ground  for  a  general  pathological 
and  nosological  discussion  we  should  be  agreed  as  to  the 
sense  in  which  a  psycho-dynamic  school  speaks  of  mental 
activities,  and  how  it  correlates  them  with  the  non-mental 
data,  the  non-mental  neurological  issues,  and  those  of  the 
non-nervous  organs.  Suffice  it  to  say  that  by  mental  activi~ 
ties  we  do  not  mean  an  expurgated  happening  in  an  abstract 
"mind,"  but  rather  those  activities  and  reactions,  those 
functions  of  our  body  in  which  phenomena  of  more  or  less 
conscious  association  are  a  necessary  feature.  The  non- 
mental  nervous  functions  are  that  which  can  be  produced  by 
electric  stimulation  or  reflex  irritability  with  or  without  con- 
scious processes.  The  non-nervous  functions  would  be  the  cir- 
culation, respiration,  nutrition,  etc.  Psychogenic  disorders  are 
those  which  depend  on  conditions  or  events  which  can  only 
be  described  satisfactorily  in  terms  of  psycho-biology; 
actions,  emotional  reactions  and    attitudes,  and  intellectual 


The  Nature  and  Conception  of  Dementia  Praecox    1 1 

or  "thought"  constellations, —  and  their  conflicts  and 
abnormal  combinations  or  atavistic  or  fundamentally  or 
directly  abnormal  reactions,  with  their  eff"ect  on  the  general 
mental  balance.  Every  mental  activity  or  reaction  leaves 
its  engram  and  has  a  certain  dynamic  value  in  the  after- 
life of  the  individual  and  his  general  economy  (which  we  call 
organic  rather  than  "physical,"  in  order  to  avoid  the  con- 
trast of  mind  and  body).  But  certain  functions  are  much 
more  determining  and  dominating  (such  as  the  instincts  and 
fundamental  longings);  and  the  bulk  of  functional  psycho- 
pathology  consists  of  the  sometimes  simple  and  sometimes 
complex  tangles  of  the  conflicting  dynamic  elements.  The 
ways  in  which  they  show  may  be  special  mental  states  or 
reactions,  disorders  of  sleep  and  dream-life,(^hysterical  and 
other  amnesias,  jpsychasthenic  ruminations,  and  other  sub- 
stitutive activities,  and  under  special  breaks  of  compensa- 
tion the  classical  psychotic  reactions.  They  will  also  entail 
disorders  in  the  submental  functions,  such  as  tremors, 
nervous  dyspepsia,  fits,  contractures,  vasomotor  disorders, 
and  disorders  of  nutrition  and  anabolism,  etc.;  or  they  may 
even  simulate  focal  diseases  of  the  nervous  system  (hemi- 
plegia, etc.).  The  essential  point  is  that  the  mechanism 
and  its  function  would  not  be  established  without  more  or 
less  conscious  "mental"  association. 

In  contrast  with  these  psychogenic  disorders  we  find 
the  more  or  less  definitely  exogenous  disorders  (toxic  or 
metabolic),  and  the  focal  disorders  of  the  nervous  system 
hardly  requiring  special  discussion  here,  since  their  mental 
symptoms  or  syndromes  essentially  determined  by  non- 
mental   disorders  implicating  the  nervous  system. 

Any  psychopathological  consideration  must  to-day  give 
unbiassed  consideration  to  these  three  aspects:^  (1)  collisions 
of  functions  as  such,  with  possible  incidental  disorders  of  the 
organic  balance  of  these  functions  (hysteria   psychasthenia, 
nervous  dyspepsia,  and  other  conflicts  of  function) ;   (2)  the     -      ^ 
plainly  and    essentially  submental   toxic  or  metabolic  ill-     ^  r  , 
adjustments     (alcoholic,    metasyphilitic    processes,    hyper-      "^•^ 
and  hypothyroidism,  etc.);   (3)  the  role  of  factors  attacking 
more  or  less  localized  mechanisms  of  neurological  balance, 
such  as  the  hypothetical  frontal  lobe  mechanisms  of  Kleist 


12  Dementia  Praecox 

(symptom-complexes    produced    by   focal    lesions,    tumors, 

etc.). 

Pathology  of  to-day  must  work  with  all  these  types 
of  integration  without  favoritism,  and  show  just  how  far 
any  one  of  the  individual  components  can  do  justice  to  the 
explanation  of  any  experiment  of  nature. 

Let  us  now  return  to  the  data  in  dementia  praecox. 
Economy  of  time  forces  me  to  suppress  the  details  of  the 
actual  mechanisms  in  the  original  constellation  and  evolu- 
tion of  dementia  praecox,  as  they  are  assigned  to  Dr.  Jelliffe 
and  to  Dr.  Hoch.  I  should  really  give  them  the  floor  and 
then  give  my  review  of  the  additional  issues : )  first,  consider 
the  factors  in  the  prediagnostic  stage,  i.e.,  the  material  out 
of  which  the  disorder  grows,  which  Dr.  Jellifl"e  is  expected 
to  treat,  and  the  mechanisms  to  be  described  by  Dr.  Hoch, 
which  show  how  the  process  is  started  and  more  or  less 
established,  and  then  the  wider  aspects  with  a  summing  up 
of  the  net  result. 

Whatever  the  material  furnished  would  be,  I  have  to  dis- 
cuss the  three  lines  of  interpretations,  the  special  metabolism 
and  toxic  states  of  the  initial  period  and  the  established 
dementia  praecox,  any  autonomous  neurological  data,  and 
the  scope  of  psychogenic  events  with  their  submental  im- 
plications. 

Of  the  metabolism  and  toxic  states  the  best  investi- 
gators have  so  far  least  to  say.  The  claims  differ  and  cer- 
tainly do  not  show  anything  specific  or  decisive  so  far. 
Hyperthyroidism,  the  sex  glands,  peculiar  blood  states,  and 
other  conditions  have  been  accused  with  the  most  fragmen- 
tary evidence.  They  form  interesting  issues  of  general 
pathology,  but  no  adequate  material  for  a  causal  recon- 
struction of  the  facts  in  our  cases  so  far. 

The  neurological  data  are  meager.  The  most  syste- 
matic consideration  in  this  direction  is  that  by  Kleist, 
brilliantly  speculative  and  referring  only  to  the  motility 
psychoses,  and  that  not  in  a  nosological  sense.  The  isolated 
facts,  the  fronto-cerebellar  disorders,  tremors,  reflex  alter- 
ations, dermatographia,  seborrhcea,  the  eye  symptoms 
(including  Dodge's  and  Diefendorf's  interesting  observa- 
tion on  the  eye  movements),  appear  like  elements  in  the  gen- 


The  Nature  and  Conception  of  Dementia  Praecox   13 

eral  procession,  but  not  like  helps  for  an  explanation.  We 
simply  have  to  try  and  respect  them  as  material  on  which  to 
bring  our  hypotheses  to  a  test.  The  histological  data  are 
not  unequivocal,  but  mainly  of  a  character  which  might  as 
well  be  merely  incidental  to  the  functional  disorders,  and 
Koch's  interpretation  of  the  chemical  findings  culminates 
mainly  in  defective  oxydation.  The  differentiation  of  various 
disease  forms  according  to  special  localization  of  the  maxi- 
mum disorder  might  as  well  be  the  consequence  as  the  cause 
of  special  symptom-complexes.  From  a  practical  view- 
point, it  certainly  is  more  important  to  make  the  most  of 
the  initial  weakness  and  to  see  whether  it  can  be  determined 
and  followed  in  the  functional  constellation. 

The  data  of  conduct  and  behavior  and  of  reactive  mate- 
rial of  the  patients  have  certainly  proved  most  directly 
helpful  in  the  understanding  of  the  developments. 

We  find  here  two  tendencies, —  the  one  of  Freud  and 
Jung,  which  emphasizes  concrete  experiences  and  reactive 
complexes  thereto,  and  the  less  specific  attempt  to  formu- 
late the  loss  of  balance  attempted  by  me,  on  ground  of 
habit  deterioration  and  tantrums  or  more  lasting  reactions 
biologically  unfavorable  to  restitution  to  a  normal  attitude, 
sometimes  with  evidence  of  short-circuits,  but  always  with 
more  or  less  characteristic  mechanisms  which  may  ulti- 
mately deserve  differentiating  instead  of  our  having  to  bring 
the  after  all  heterogeneous  mass  into  too  large  a  disease 
unit.  The  two  viewpoints  form  no  contrast;  the  con- 
cept of  complexes  really  furnishes  most  fruitful  material  and 
issues  of  research,  while  in  other  cases  the  habit  conflicts 
offer  a  better  formulation  of  the  broad  lines  and  possibly  the 
only  material  accessible. 

As  in  almost  all  disease  forms  with  which  we  deal, 
including  the  plainly  exogenous  ones,  we  are  far  from  dealing 
with  simple  etiological  constellations  in  the  mental  disorders 
of  the  deterioration  group.  The  main  contrasts  or  extremes 
are  the  cases  with  strong  constitutional  bias  requiring  but 
little  extraneous  cause, —  and  those  with  at  least  super- 
ficially more  normal  makeup  and  a  preponderance  of  overt 
more  or  less  extraneous  or  circumstantial  etiological  factors. 
The  essential  in  both  extremes  and  in  the  intermediary  cases 


5^^*«rari|  at 


14  Dementia  Praecox 

.,     is  the  break  of  compensation  of  adjustment  with  more  or 

\  )  less  deficit  and,  in  most  cases,  with  the  peculiar  attempts  at 

balance   and   reconstruction   which   constitute   the   glaring 

surface  picture  of  the  clinical  description  and  the  special 

mechanisms  of  the  analytical  consideration. 

While  undoubtedly  a  large  number  of  cases  are  beyond 
complete  analysis  and  understanding,  there  is  a  growing 
number  of  cases  in  which  definite  types  of  breakdown  are 
being  demonstrated,  which  Dr.  Hoch  will  discuss  more 
specifically.  The  general  form  of  the  breakdown  is  per- 
haps superficially  much  like  that  of  other  types,  for  up  to 
this  day  "mania  "  and  "melancholia  "  and  "confusional 
insanity "  and  "paranoia"  embrace  in  the  vulgar 
psychiatry  the  recoverable  cases  and  also  those  tending 
to  deterioration.  But  beneath  this  superficial  coating  the 
extremes  of  non-deteriorating  or  deteriorating  processes 
show  clearly  different  constellations  and  a  different  working 
out  of  the  events,  so  that  even  the  ordinary  routine  man 
knows  the  contrasts.  There  are,  as  far  as  I  can  see,  a  few 
general  features  in  evidence  that  mark  the  dementia  praecox 
course:  The  oddity,  unnaturalness,  and  incongruity  of  the 
entire  picture,  in  the  face  of  relative  clearness,  and  the 
tendency  to  turn  on  definite  complexes,  and  these  especially 
in  spheres  which  are  difficult  to  reach  for  an  adjustment. 
(^  The  more  the  odd  and  unaccountable  features  prevail  and 
•  involve  the  fundamental  instincts  and  longings,  the  greater 
the  chance  for  an  unfavorable  course;  further,  the  more 
clearly  we  have  evidence  of  not  otherwise  justified  disso- 
ciation processes  and  of  paranoid  developments,  the  more 
likely  is  the  fate  of  the  patient  sealed. 

There  is  a  striking  narrowing  of  the  resources  of  ade- 
quate reaction  and  then  either  a  scattering  or  a  prevalence 
of  tension,  and  from  the  intellectual  point  of  view,  varying 
degrees  of  more  or  less  distinctly  morbid  reconstruction  of  a 
suitable  personality,  with  more  or  less  paranoid  results. 
The  fixation  of  the  disorders  and  of  the  defect  is  an  inevi- 
table consequence  or  correlate  of  the  extent  of  recuperability 
of  the  psychobiological  material  and  mechanisms. 

The  condition  undoubtedly  goes  in  some  cases  with  a 
•^decided  breakdown  of  cerebral  material,  marking  an  acute 


The  Nature  and  Conception  of  Dementia  Praecox    15 

delirium  or  perhaps  an  acute  stupor  suggesting  submental 
factors.  In  other  cases  the  phenomena  of  such  wholesale 
and  elementary  breakdown  are  decidedly  in  the  back- 
ground and  covered  by  the  pseudo-adaptations  of  the  cata- 
tonic or  paranoid  or  hebephrenic  character,  and  charac- 
teristic forms  of  dissociative  mechanisms  to  be  discussed  by 
Dr.   Hoch. 

The  crucial  problem  is  whether  it  is  well  to  consider  such 
a  large  group  of  cases  as  a  unitary  and  necessarily  dete- 
riorative disease  process,  giving  up  the  possibility  of  indi- 
vidual prognosis,  or  whether  we  cannot  single  out  some 
special  factors  at  work,  out  of  which  we  can  construct  a 
sufficiently  accurate  formula  of  nature's  experiment?  Some 
of  us  decide  in  the  latter  direction,  for  reasons  to  be  shown 
on  well-studied  cases,  such  as  would  be  too  long  to  introduce 
in  a  symposium. 

The  two  main  arguments  which  are  raised  against  the 
dynamic  importance  of  the  psychogenic  material  are  the  pro- 
duction of  an  actual  deterioration  and  the  existence  of  actual 
alterations  in  the  brain  and  the  undoubted  fact  that  the 
release  or  start  of  the  downward  run  is  occasionally  the  out- 
come of  an  initial  exogenous  damage,  such  as  an  acute  in- 
fection, typhoid  fever,  etc.  The  first  two  points,  deteriora- 
tion and  the  existence  of  lesions,  might,  I  think,  be  dealt  with 
as  one  issue:  How  can  we  account  for  the  stabilization  on 
a  lower  mental  level,  and  what  is  the  relation  of  the  degen- 
erative histological  processes  observed  in  many  acute 
cases.''  The  other  point  I  dismiss  because  it  is  too  much  the 
exception  and  holds  for  too  few  cases;  the  majority  starting 
without  any  clear  somatic  disease. 

The  available  somatic  facts  in  most  cases  are  by  far 
in  favor  of  an  endogenous  break  of  compensation  of  ana- 
bolism  and  metabolism  rather  than  in  favor  of  a  distinct 
exogenous  disorder. 

I  am  not  a  priori  opposed  to  the  favorite  explanation 
of  all  and  every  lesion  of  the  nervous  system  on  ground  of 
the  action  of  special  toxines.  Considering  the  liberal  in- 
terpretation of  the  concept  toxine  and  the  inclusion  under 
it  of  all  disorders  of  enzymes  and  anti-enzymes  and  hor- 
mones, it  may  become  possible  to  demonstrate  some  specific 


16  Dementia  Praecox 

short  circuits  or  chemical  principles  beside  mere  deficient 
oxydation  (Koch)  in  such  processes  as  are  grouped  under 
dementia  praecox.  The  point  is  that  to-day  this  simple 
formula  is  not  available  and  therefore  a  mere  postulate,  and 
not  of  a  character  to  cause  us  to  cast  aside  the  practically 
valuable  formulations  of  the  facts  in  terms  of  defective  balance  of 
anabolism  and  catabolism  and  in  terms  of  disastrous  constella- 
tions of  activities  and  reactions,  which  can  actually  be  weighed 
and  used  for  an  estimate  of  the  disorder,  its  cause,  course, 
and  outcome.  An  unreserved  objection  would,  however 
turn  against  the  original  Kraepelinian  theory  of  disorders 
of  metabolism,  which  puts  myxcedema,  general  paralysis, 
and  dementia  praecox  on  the  same  principle  of  disorder  of 
some  as  yet  undetermined  organ  or  mechanism,  which  in 
turn  affects  the  metabolism  so  as  to  involve  the  brain,  to 
produce  with  merely  submental  poisons  special  symptom 
complexes  and  to  constitute  a  danger  of  permanent  damage. 
For  this  the  constitutional  mental  bias  is  too  distinctive  to  be 
neglected.  The  possibility  of  alterations  of  the  nervous 
system  as  a  necessary  occurrence  incidental  to  normal  and 
abnormal  psychobiological  reaction  may,  of  course,  appear 
very  small  to  those  who  consider  nervous  function  chiefly  a 
physical  process  along  nerve  paths  which  show  little  chemi- 
cal alteration  in  function.  But  on  this  question  the  last 
word  is  not  spoken,  at  least  not  in  the  light  of  the  recent 
work  of  the  Cleveland  school,  which  may  well  revive  the 
interest  in  the  studies  of  Hodge  on  fatigue,  overstimulation, 
and  the  like. 

The  practical  issue  in  the  dementia  praecox  problem  to- 
day is  in  the  main  this:  Are  we  helpless  in  our  estimate  of 
the  nature,  depth,  and  prognosis  of  the  disease  as  we  see  it 
clinically  in  the  available  data  of  psychobiological  reactions? 
To  decide  that  question  I  ought  to  show  you  the  exact 
amount  of  accuracy  with  which  the  development  of  deteri- 
oration and  general  course  of  the  condition  could  be  foretold 
with  a  good  anamnesis  and  careful  observation  of  the  re- 
action type.  In  the  New  York  state  hospitals  an  effort 
is  made  to  distinguish  dementia  praecox  and  conditions  akin 
to  the  dementia  praecox  reactions.  Psychobiological  esti- 
mates make  it  possible  to  distinguish  differences  of  risks, 


The  Nature  and  Conception  of  Dementia  Praecox    17 

and  that  to  a  sufficient  extent  that  the  validity  of  a  psycho- 
genic theory  and  the  incidental  character  of  the  lesions 
appears  reasonably  supported. 

\y  For  didactic  purposes  the  simple  insistance  on  earmarks 
and  signs  of  a  "disease"  have  many  advantages;  but  it  is 
a  dangerous  method  leading  to  too  many  blunders  and 
not   enough  reserve. 

That  the  interpretation  of  the  disease  group  along 
psychobiological  lines  leaves  the  facts  in  the  form  in  which 
they  are  experienced  and  gives  us  valuable  helps  in  the  hand- 
ling of  the  cases,  is  obvious  to  all  those  who  work  with  the 
method.  That,  of  course,  the  therapeutic  net  results  are 
usually  negative  and  rarely  clearly  positive,  is  so  much  a 
necessary  or  inevitable  fact  that  our  conception  should  not 
give  rise  to  false  therapeutic  hopes. 

Without  encroaching  on  the  concrete  material  of 
makeup,  etiological  constellations  and  mechanisms,  it  is  not 
possible  to  discuss  adequately  the  question  what  constitutes 
the  actual  establishment  of  a  process,  which  deserves  the 
term  dementia  prsecox,  a  point  of  great  importance  for  a 
clear  conception  of  the  disorders  and  for  the  differential 
diagnosis. 

J  My  own  conception  is  an  attempt  to  make  the  most  of 

the  facts  available  to-day,  and  among  these  are  specially 
prominent  those  of  makeup  and  of  psychobiological  adjust- 
ments. If  it  should  lead  to  obstruction,  I  should  be  the  first 
to  assign  it  its  place.  So  far,  evidence  seems  to  favor  the 
view  that  dementia  praecox  is  essentially  unlike  general 
paralysis,  and  more  likely  the  usually  inevitable  outcome  of 
(1)  conflicts  of  instincts,  and  more  concretely  put,  conflicts 
of  complexes  of  experience,  and  (2)  incapacity  for  a  harmless 
constructive  adjustment.  The  mechanism  is  to  quite  an 
extent  intelligible  in  psychobiological  terms.  The  histo- 
logical alterations  are  to  quite  an  extent  a  problem  akin  to  pro- 
cesses of  anabolism  and  catabolism.  A  quest  for  further 
short-cuts  for  organic  processes  is  in  no  way  discouraged. 
There  are  those  who  go  so  far  as  to  expect  that  the  physi- 
cian's task  should  be  to  find  ways  to  make  even  the  most 
undesirable  and  pernicious  performances  harmless  and  that 
anything  short  of  direct  remedy  is  equal  to  complete  igno- 


18  Dementia  Praecox 

rance.  Let  us  not  forget  that  the  pre-eminently  psycho- 
genic conception  of  dementia  praecox  formulates  the  clinical 
problem  so  that  in  some  cases  at  least  dangerous  constella- 
tions can  be  pointed  out  in  time.  At  the  same  time  it  for- 
mulates problems  of  investigations,  and  would  not  seem  to 
be  as  likely  to  block  necessary  investigations  as  the  exclusive 
faith  in  merely  hypothetical  poisons  and  as  yet  unexplained, 
but  after  all  most  probably  incidental  lesions,  wholly  sacrifi- 
cing the  fruitful  field  of  psychobiology. 


PREDEMENTIA  PRiECOX;  THE  HEREDITARY 

AND  CONSTITUTIONAL  FEATURES  OF 

THE  DEMENTIA  PRECOX  MAKEUP 


PREDEMENTIA  PR.ECOX;  THE  HEREDITARY 

AND  CONSTITUTIONAL  FEATURES  OF 

THE  DEMENTIA  PRECOX  MAKEUP 

BY    SMITH    ELY    JELLIFFE,  M.D.,    PH.D. 

PUT  in  the  shortest  manner  and  in  the  most  definite 
language,  the  problem  which  I  bring  to  your  at- 
tention as  a  part  of  this  general  discussion  on 
dementia  praecox  is  as  follows:  Granting  for  the 
time  being  that  we  are  justified  in  assuming  that  there  is 
a  group  of  individuals  who,  for  reasons  as  yet  but  little 
understood,  have  a  tendency  to  develop  a  progressive  de- 
menting process,  of  a  fairly  definite  and  specific  character, 
showing  itself  in  its  end  phases  in  a  typical  disturbance  of 
conduct  based  on  the  destruction  or  deterioration  of  certain 
fundamental  mental  mechanisms,  is  it  logical  to  assume 
that  what  we  recognize  as  the  disease  process  proper,  which 
from  its  inception  travels  a  well-beaten  track,  is  preceded 
by,  or  better  is  made  possible  by,  the  occurrence  of  a  fairly 
definite  constitutional  makeup,  or  character,  in  the  candi- 
dates who  finally  develop  the  disease?  If  so,  what  are  the 
mental  and  physical  features  of  this  makeup;  from  whence 
and  by  what  processes  does  it  come  to  be,  and  finally,  can 
we,  by  recognizing  its  features,  in  its  predemential  stages, 
avoid,  abort,  or  mitigate  the  after-coming  catastrophe? 

Are  we  permitted,  from  the  studies  available,  to  assume 
a  predementia  prsecox  character  —  a  term  used  by  me  in 
1907,  and  used  by  Mingazinni  in  a  modified  form  later  in 
the  same  year  as  dementia  praecocosissima,  to  express  a 
slightly  different  concept,  namely  a  juvenile  prsecox?  Are 
its  characters  sufficiently  definite  to  warrant  the  utilization 
of  the  concept  as  a  therapeutic  point  of  departure? 

Kraepelin  himself  has  never  done  anything  more  than 
claim  that  the  dementia  praecox  generalization  is  a  working 
hypothesis.  He  alludes  to  the  group  as  a  whole,  as  a 
"topf" — a    basket    into   which,    for   practical    reasons,    a 


22  Dementia  Praecox 

number  of  apparently  similar  things  have  been  thrown,  al- 
though many  of  them  probably  do  not  belong  there.  His- 
torical retrospection,  however,  shows  that  the  general 
paresis  concept  has  developed  along  quite  similar  lines,  and 
yet  no  one  would  throw  over  the  paresis  concept  because 
of  the  exceptions  and  the  mistakes  in  diagnosis.  Surely 
no  one  cares  to  exclude  general  paresis  from  nosology 
because  ten  per  cent  of  cases  resembling  it  may  be  shown 
to  be  due  to  some  other  disease  on  last  analysis. 

It  must  be  admitted  that  in  the  prsecox  basket  the 
percentage  of  things  that  are  quite  dissimilar  is  probably 
much  larger,  but  the  question  of  much  more  import  still 
remains,  that  there  does  exist  a  certain  nucleus  of  cases, 
and  that  a  very  large  one,  that  run  an  essentially  similar 
course,  and  that  probably  have  an  extremely  close  etiologi- 
cal and  hereditary  relationship. 

It  is  not  within  the  province  of  this  discussion  to  enter 
into  the  pathological  problem,  yet  the  evidence  is  accumu- 
lating that  tends  to  substantiate  the  view  that  a  fairly 
definite  pathology  will  be  found  underlying  a  large  number 
of  the  praecox  cases. 

There  is  a  marked  tendency  for  the  process  to  become 
diffused,  and  to  invade  the  entire  cerebrum,  so  that  to  the 
more  striking  mental  signs  are  added  physical  signs  of  almost 
as  definite  a  character  as  those  met  with  in  paresis. 

It  also  is  becoming  apparent  that  the  interpretation  of 
dementia  praecox  must  be  made  much  wider  —  in  the  clinico- 
anatomical  sense  —  and  that  the  evolution  of  its  interpre- 
tation must  follow  much  the  same  broad  general  lines  that 
have  been  traveled  in  the  paresis  domains.  The  clinical 
pictures  are  bound  to  begin  in  a  slightly  different  manner, 
according  to  the  anatomical  localization  of  the  process. 
The  course  will  vary  by  reason  of  the  same  factors  of  varia- 
bility in  attack  of  the  pathological  alteration,  and  the  general 
end  level  will  be  reached  largely  as  in  paresis  by  the  more 
or  less  general  diffusion  of  the  process  in  the  areas  of  special 
predilection. 

At  the  same  time  we  must  recognize  that  the  alterations 
go  on  much  more  slowly,  that  the  localized  processes  affect- 
ing fundamental  mechanisms  are  less  constant,  and  the  end 


Features  of  the  Dementia  Praecox  Makeup         23 

results  less  uniform  than  in  the  great  prototype  paresis. 
In  one  general  trend  in  particular,  i.  e.,  the  katatonic 
syndromes,  it  is  highly  probable  that  anatomical  and 
clinical  correlations  will  be  found  to  be  impossible  in  a  great 
number  of  cases,  by  which  I  mean  more  particularly,  that 
like  the  epilepsies,  quite  dissimilar  pathological  alterations 
will  be  found  responsible  for  the  katatonic  reactions. 

Already  there  are  numerous  autopsied  cases  on  record 
which  show  a  multiplicity  of  essentially  different  types  of 
lesions,  associated  with  the  katatonic  syndrome.  This  is 
not  a  new  problem  to  the  psychiatrist,  however,  who  has 
to  bear  in  mind  as  analogous  the  pseudo-paretic  syndromes 
of  brain  tumor,  of  alcoholism,  of  arteriosclerosis,  or  of 
tertiary  cerebro-spinal  syphilis,  etc.  That  our  pathological 
analyses  some  day  will  encompass  the  unravelling  of  the 
disturbed  functionally  active  paths  seems  undoubted, 
but  the  dreams  of  Meynert  and  of  Wernicke,  more  particu- 
larly, not  to  mention  their  later  followers,  are  still  far  from 
being  realized.  Others  who  will  follow  me  may  deal  more 
thoroughly  with  this  aspect  of  the  question. 

I  am  quite  well  aware  that  I  have  expressed  myself 
somewhat  more  didactically  in  the  matter  of  pathology 
than  those  who  incline  to  a  more  functional  view  of  dementia 
prsecox  are  prepared  to  accept.  I  freely  admit  that  we  are 
still  much  at  sea  in  this  matter,  and  am  fully  prepared  to 
follow  Meyer  in  part  in  a  more  functional  interpretation 
of  certain  of  the  dementia  praecox  reactions.  Any  attempt 
to  recognize  a  fundamental  personality  is  directly  opposed 
to  a  too  dogmatic  pathological  interpretation.  After  all, 
our  pathological  findings  may  represent  atrophies  of  unused 
association  tracts  which  have  resulted  from  the  so  to  speak 
petrification  of  bad  habits  of  mental  adjustment. 

If  we  are  to  gain  any  light,  then,  on  the  typical  praecox 
cases,  using  the  phrase  here  in  a  manner  quite  similar  to  the 
conception  of  typical  paresis,  it  becomes  incumbent  upon 
us  to  gain  a  better  insight  into  the  etiology. 

This  concerns  itself,  so  far  as  I  can  see  it,  with  at  least 
two  factors.  One  is  the  intangible  intoxication  process, 
of  as  yet  unknown  origin,  which  has  been  advanced  by 
Kraepelin  himself,  and  partly  supported  by  many  students 


24  Dementia  Praecox 

of  the  problem,  largely  on  grounds  of  analogy.  This  feature 
of  the  subject  I  cannot  take  up  here,  and  can  only  refer 
to  the  excellent  and  comparatively  recent  contribution  by 
Saiz,'  on  the  presence  of  physical  anomalies  in  dementia 
praecox  and  their  bearing  on  the  etiology.  Here  may  be 
found  a  complete  discussion  of  the  question  of  organic 
changes,  autointoxication  and  the  like.  Weber's^*  recent 
summary  may  also  be  consulted  to  advantage. 

The  second  is  the  problem  we  have  set  ourselves  to 
state,  namely,  is  there  a  particular  makeup  which  lends 
itself  per  se  to  an  abiatrophy,  a  habit  deterioration  or  to  a 
special  invulnerability  to  unknown  toxic  factors. 

In  the  nearer  consideration  of  the  makeup  one  looks 
for  help  to  heredity  and  to  environment,  to  the  ancestral 
features,  and  to  educative  factors,  taken  in  the  broadest  sense. 

Up  to  the  present  time,  all  of  our  efforts  at  estimating 
the  hereditary  factors  are  purely  retrospective.  After 
the  thing  has  happened,  we  try  to  go  back  and  see  why. 

In  my  first  paper  on  predementia  praecox,^  I  pointed 
out  some  of  the  difficulties  met  with  in  attempting  to 
analyze  these  factors  which  we  group  loosely  together,  and 
call  heredity.  The  great  bane  of  psychiatry  seen  from  this 
vantage  point  has  been  the  hopeless  confusion  of  statistical 
studies  due  to  a  lack  of  fundamental  nosological  conceptions. 
Unlikes  are  continually  being  swallowed  in  the  numerical 
mean,  and  further,  no  cognizance  is  taken  of  the  numerous 
intercurrent  factors  which  produce  results  independent  of 
constitutional  qualities.  Whether  we  are  to  escape  such 
loose  interpretations,  even  with  the  apparently  firmer 
foundations  of  Kraepelin's  generalizations  is  highly  doubt- 
ful, since  there  is  little  question  that  the  dementia  praecox 
group,  as  at  present  delimited,  is  much  too  large,  and  shows 
at  least  three  somewhat  dissimilar  trends.  Should  these 
prove  to  present  more  dissimilarities  it  will  become  idle 
to  discuss  the  heredity  of  dementia  praecox,  just  as  it  has 
become  senseless  to  speak  of  the  heredity  of  insanity. 
Coincidence  is  not  causality,  and  we  are  in  need  of  much 
better  standards  of  logic  and  accuracy  in  gathering  facts 
to  prevent  the  hazy,  lazy  generalizations  regarding  heredity 
to  pass  muster.' 


Features  of  the  Dementia  Praecox  Makeup        25 

The  high  standard  that  has  been  set  up  by  the  labors 
of  Pearson,  Welden,  Brachet,  and  their  co-workers  in  the 
field  of  general  heredity;  the  special  work  of  Jennie  KoUer/ 
Diem,'  Strohmayer,^  Tigges,^  and  Mayet,*  shows  us  that 
practically  all  of  the  work  that  has  been  done  in  the  study 
of  heredity  in  the  psychoses  is  extremely  primitive.  We 
include  the  work  of  the  biometricians  themselves  within  this 
criticism.  These  working  in  a  strange  field  have  been  unduly 
influenced  by  a  term  —  insanity  —  and  have  approached 
the  nonsensical  in  their  attempt  at  analyzing  so  many 
diverse  conditions  grouped  under  a  legal  rather  than  a 
medical  concept.  As  Wagner  v.  Jauregg  has  termed 
it,  hereditary  statistics  has  become  a  narcotic  that  leads 
to  deceptive  conclusions. 

Frankly  admitting,  however,  that  with  the  present 
outlook  our  data  concerning  hereditary  factors  in  dementia 
praecox  itself  must  be  accepted  with  great  critical  reserve, 
it  may  still  be  worth  while  to  briefly  recapitulate  what 
inferences  have  been  drawn  by  previous  workers  for  the 
sake  of  seeing  the  shortcomings  and  offering  some  sugges- 
tions as  to  how  they  may,  perhaps,  be  improved.  Until 
unit  characters  can  be  ascertained  for  dementia  praecox; 
until  it  can  be  shown  that  it  is  not  an  exogenous  or  even  an 
endogenous  toxemia;  until  we  know  that  a  uniform  funda- 
mental disease  process  is  operative,  only  when  these  under- 
lying factors  are  more  clearly  perceived  shall  we  be  in  a 
position  to  correctly  estimate  the  influence  of  hereditary 
factors  if  there  are  any. 

In  my  previous  paper  I  collected  the  so-called  data 
available  to  that  time,  1907.  Therein  appeared  most 
general  statements.  Thus  Kraepelin's^  figures  that  at 
least  seventy  per  cent  of  the  praecox  cases  show  the  presence 
of  hereditary  factors,  of  which  only  seventeen  or  eighteen 
per  cent  is  found  in  direct  ancestry.  Illberg^°  speaks  of  a 
twenty  per  cent  heredity,  Clauston"  says  heredity  is  always 
present,  but  he  is  speaking  of  his  much  broader  and  more 
loosely  defined  group  of  adolescent  insanities:  Mendel," 
Strohmayer,'^  Kalmus,'^  Pickett, '^  all  give  general  state- 
ments which  are  of  little  definite  value.  Certain  more 
specific  studies,  however,  are  available.      Krauss,'^  working 


26  Dementia  Praecox 

with  very  few  cases,  showed  a  high  percentage  of  similar 
heredity  in  the  ascendants,  thirteen  cases  of  dementia 
praecox  in  ascendants  showing  as  many  as  fourteen  in  the 
descendants.  One  raises  a  query  as  to  the  diagnosis  In 
his  manic  depressive  cases.  Vorster's  work  also  bears 
directly  upon  the  question.  His  is  practically  the  first 
satisfactory  and  painstaking  general  survey  of  the  problem.'^ 
He  shows  that  all  of  the  families  with  dementia  praecox 
In  the  ascendants  showed  dementia  praecox  In  the  descen- 
dants, and  that  in  cases  of  Inbreeding  of  cousins  dementia 
praecox  was  frequent.  The  praecox  cases  showed  the  vari- 
able trends  of  modern  standards.  Hebephrenic,  catatonic, 
and  paranoid  cases  were  intermingled  in  the  heredity,  an 
Indirect  evidence  of  the  close  relationship  of  these  types. 
Sloli's*^  study  points  in  the  same  direction. 

"My  own  observations*  on  well-authenticated  cases  of 
dementia  praecox  which  I  have  been  able  to  follow  for  many 
years,  and  whose  parents  have  been  well  known  to  me,  have 
shown  that  three  elements  have  been  most  emphasized  In 
the  ancestry;  dementia  praecox  Itself,  alcohol,  and  abnormal 
personality.  Alcoholic  parents  have.  In  my  experience, 
been  most  responsible  for  the  hebephrenics;  In  many  in- 
stances the  alcoholism  has  been  a  symptom  of  profound 
neurasthenia  or  even  a  dementia  praecox  at  a  more  advanced 
age,  to  which  it  In  turn  has  contributed,  and  established 
a  vicious  circle  which  has  left  Its  Impress  in  heredity.  Patho- 
logical characters  have  constituted  another  most  striking 
feature  in  my  series  of  cases.  Marital  incompatibility, 
due  to  the  inability  of  one  or  both  parents  to  adapt  them- 
selves to  common-sense  relations,  has  been  a  significant 
factor  in  the  parentage  of  many  of  the  paranoid  dements 
that  I  have  been  able  to  know  well  in  the  predementia 
stages.  Very  often  this  incompatibility  is  only  an  index  of 
a  mind  already  with  its  paranoid  trend.  This  has  had 
a  marked  Influence  on  the  education  as  well,  which  point 
properly  belongs  to  the  subject  of  our  Inquiry.  One  other 
class  may  be  termed  the  "derelicts,"  themselves  in  all 
probability  suffering  In  some  slight  degree  from  dementia 
praecox  coming  on  later  in  life,  or  Incomplete  dilapidations 
due  to  an  early  attack  of  praecox  with  partial  recovery. 


Features  of  the  Dementia  Praecox  Makeup         27 

Many  of  these  group  themselves  in  the  alcoholic  class,  since 
with  the  advent  of  manhood  they  sink  back  in  the  struggle 
for  subsistence  and  are  unable  to  compass  more  than  small 
clerical  positions.  Many  of  these  are  the  semifailures  of 
life,  those  pushed  aside  in  the  struggle,  and  forced  to  be 
content  with  small  returns.  In  my  experience  this  class 
has  contributed  the  greater  number  of  all  classes  of  pre- 
cocious dements  to  the  population."  Many  of  these  are  the 
dementia  tardivas  of  Stransky. 

In  the  three  years  that  have  passed  we  have  had  several 
more  contributions  to  the  subject.  Pilcz'^  has  given  a  care- 
ful study  of  two  thousand  cases  in  which  it  would  appear 
that  in  the  ascendants  of  dementia  praecox  cases  (plus 
katatonics  which  are  given  a  separate  nosological  position) 
abnormal  characters  appear  in  a  very  striking  high  per- 
centage —  thirty-three,  neuropathies  as  high  as  fifty-nine 
per  cent,  -f  Pilcz  also  finds  that  tabes  and  general  paresis 
are  not  infrequent  in  the  ascendants.-.'*  Hebephrenia  is  the 
commonest  types  seen  with  tabes  in  the  ancestors.—' Pilcz 
here  offers  some  food  for  thought  relative  to  the  general 
subject  of  the  relationship  of  syphilis  to  abiatrophy.-  Para- 
noid trends  of  the  praecox  type  were  frequent  in  both  parents 
and  children.  Katatonics  showed  alcoholic  parents  in 
high  percentage.  The  studies  of  Pilcz  confirm  the  general 
standpoint  of  similar  hereditary  transmission  maintained  by 
many.  This  is  naturally  in  accord  with  Mendelian 
concepts  and  its  apparent  confirmation  lends  added  weight 
to  the  value  of  the  Krsepelian  nosological  conceptions. 
Incidentally  the  thought  may  be  expressed  that  we  have 
almost  advanced  to  the  point  when  knowledge  of  the  psy- 
chosis in  the  parents  may  clear  up  a  difficult  diagnosis  in 
the  child.  This  is  particularly  valuable  in  the  differentia- 
tion of  manic  depressive  from  dementia  praecox  cases. 

The  subject  of  heredity  in  dementia  praecox  is  handled 
specifically  by  Wolfsohn  from  material  in  Burgholzi  in 
Zurich.^"  In  all  six  hundred  and  forty-seven  cases  were 
studied,  for  ninety-seven  of  which  no  history  could  be 
obtained;  five  hundred  and  fifty  cases,  therefore,  came  up 
for  consideration.  Of  these  no  hereditary  history  could 
be   obtained   in   fifty-six   patients.     Thus   ninety  per   cent 


28  Dementia  Praecox 

showed  heredity  of  some  sort,  and  the  author  includes 
mental  disease,  nervous  disease,  alcoholism,  abnormal 
characters  in  both  direct  and  indirect  lines.  The  admission 
of  so  many  factors  tends  to  reduce  the  value  of  the  study, 
and  gives  us  only  general  conclusions.  Thus  in  fifty  per 
cent  of  the  katatonics,  forty-seven  per  cent  of  the  hebe- 
phrenics, and  forty-five  per  cent  of  the  paranoid  cases, 
mental  disease  was  present  in  the  ascendants.  In  twenty 
per  cent  of  the  katatonics,  twenty-two  per  cent  of  the 
hebephrenics,  and  twenty  per  cent  of  the  paranoids  nervous 
disease  (Including  nervousness)  was  present.  In  seventeen 
per  cent  katatonics,  eighteen  per  cent  hebephrenics,  and 
twenty  per  cent  paranoids  alcoholism  was  present,  while 
for  thirteen  per  cent  of  the  hebephrenics,  thirteen  per  cent 
of  the  katatonics,  and  fifteen  per  cent  paranoids  peculiar 
characters  were  present  in  the  ascendants.  The  author 
does  not  believe  In  the  principle  of  similar  heredity,  and  it 
would  be  difficult  to  understand  just  how  a  close  mathe- 
matical study,  such  as  this  Is,  could  throw  much  light 
on  this  aspect  of  the  subject. 

In  a  short  discussion  before  the  Psychiatric  Socletyof  the 
Rhine  Provinces,  Forster^'  speaks  In  favor  of  there  being 
direct  similar  heredity  in  dementia  prsecox.  The  study 
of  Rosa  Kreichgauer"  points  very  definitely  In  the  same 
direction,  and  Is  of  special  Interest  because  she  has  ap- 
proached the  problem  in  an  unusual  manner.  She  has 
shown  that  among  members  of  the  same  family  that  there 
is  a  marked  tendency  for  similar  heredity  in  brothers  and 
sisters,  and  that  both  dementia  praecox  and  manic  depressive 
insanity  in  the  parents  show  as  similar  psychoses  in  the 
descendants.  BIschoff  22^  Jahrb.  f.  Psy.  u.  Neur.  1905,  26, 
p.  109,  has  made  contribution  along  this  same  line. 

While  revising  this  proof  I  have  received  the  very  Inter- 
esting and  thorough  study  of  Berze.(29) 

This  author  utilizing  practically  the  same  material  as 
Pilcz,  already  noted,  has  made  a  number  of  detailed  family 
studies,  and  has  brought  out  a  great  mass  of  material 
tending  to  prove  similar  heredity  for  dementia  praecox.  It 
is  gratifying  to  the  writer  to  note  that  Berze  lays  identical 
stress  upon  practically  the  same  factors  that  I  spoke  of  in 


Features  of  the  Dementia  Praecox  Makeup  29 

my  1907  paper;  namely  dementia  praecox  itself,  abnormal 
characters,  which  I  interpreted  as  probably  mild  paranoidal 
types  themselves,  and  alcoholism.  My  own  suggestions 
regarding  these  factors,  drawn  from  a  much  smaller  amount 
of  material  than  that  of  Berze,  and  confessedly  much  less 
thoroughly  studied,  have  been  most  amply  corroborated 
and  elaborated  in  Berze's  study. 

His  results,  even  a  short  summary  of  which  can  hardly 
do  justice  to  his  study,  offers  such  a  striking  confirmation  of 
my  own  opinions  that  I  desire  to  reproduce  them  here. 

In  his  summary  he  says: 

1.  Even  if  I  cannot  bring  any  figures  of  my  own  which 
speak  for  the  frequency  of  cases  of  dementia  praecox,  show- 
ing the  action  of  similar  heredity,  still  I  can  state  on  the 
basis  of  my  own  observations  that  all  statistical  studies 
concerning  this  factor  must  give  too  small  figures,  since 
they  are  not  taken  in  a  manner  to  include  under  the  definite 
rubric  of  similar  heredity  not  only  dementia  praecox  cases, 
but  other  psychoses  and  psychopathic  conditions  in  the 
ascendents  which  are  certainly  to  be  recognized  as  an  ex- 
pression of  the  praecox  constitution. 

2.  Further,  the  so-called  abnormal  character  is  often 
nothing  more  than  an  ensemble  of  developed  psychopathic 
appearances  of  a  mild  grade,  which  is  to  be  taken  as  the 
expression  of  the  praecox  constitution. 

3.  Further,  many  cases  of  chronic  alcoholism  and  of 
alcoholic  psychoses  should  be  included  for  similar  heredity; 
since  the  alcoholism  is  often  secondary,  on  the  basis  of  the 
disposition  to  dementia  praecox,  and  not  infrequently  the 
expression  of  a  distinct  dementia  praecox,  namely  a  hebe- 
phrenia. But  the  so-called  alcoholic  psychoses  on  closer 
investigation  reveal  themselves  to  be  nothing  more  than 
demented  processes  belonging  to  the  dementia  praecox 
group,  but  with  alcoholic  complications. 

4.  Many  late  dementia  forms,  namely  the  dementia 
tardiva  of  Stransky,  certain  cases  of  presenile  delusions  of 
influence,  probably  also  a  large  number  of  the  so-called 
melancholias  of  involution,  possibly  also  many  cases  of 
presbyophrenia,  falsely  diagnosed  as  dementia  senilis, 
belong  to  the  dementia  praecox  group  when  one  takes  the 
fundamental  constitution  into  consideration. 


30  Dementia  Praecox 

5.  Further,  then,  there  are  also  "Degenerative  Psy- 
choses," which  develop  on  the  basis  of  the  praecox  anlage, 
as  well  as  upon  other  psychopathic  constitutions. 

6.  General  paresis  positively  stands  in  close  hereditary 
relationship  to  dementia  praecox,  but  not  so  close  as  Pilcz 
maintains,  so  that  similar  heredity  should  occupy  a  position 
secondary  to  that  of  the  taint  of  paresis  from  the  parents. 
Even  if  it  cannot  be  maintained  that  the  predisposition 
to  paresis  may  be  identical  with  the  praecox  anlage,  yet 
nevertheless  there  is  no  necessary  antagonism  between  the 
two  constitutions. 

A  second  factor  that  remains  to  be  examined  is  that  of 
tire  and  fatigue.  It  would  be  unnatural  to  find  a  concord- 
ance of  opinion  with  reference  to  the  influence  of  fatigue 
on  the  nervous  system  of  adolescents.  The  vehemence, 
and  one  might  say,  almost  violence,  of  those  who  advocate 
reduced  educational  schedules  on  the  ground  of  their  in- 
ducing excessive  fatigue  in  children  and  young  adults, 
with  consequent  nervous  and  mental  reactions,  has  its 
counterpart  in  the  extreme  position  of  the  sceptics  who 
claim  never  to  have  seen  any  results  of  intellectual  fatigue. 
It  is  more  than  probable  that  the  natural  adjustments  of 
the  abnormally  formed  adolescent  to  the  influences  of  fa- 
tigue (laziness,  distraction,  etc.)  will  prove  sufficiently 
protective,  yet  for  the  adolescent  with  some  of  the  hereditary 
factors  already  outlined,  it  is  a  fact  the  significance  of 
which  cannot  be  controverted  that  fatigue  is  a  highly  im- 
portant element  in  their  mental  breakdown.  So  that  while 
some  may  fail  to  be  impressed  by  some  of  the  many  care- 
fully conducted  psychological  studies  into  the  influences 
of  fatigue,  these  studies  nevertheless  show  in  a  graphic 
manner  that  which  clinical  experience  has  amply  demon- 
strated. School  work  is  not  the  only  cause  of  fatigue,  by 
any  means,  but  it  plays  a  role  in  the  genesis  of  the  neu- 
rasthenoid  background  which  is  so  prominent  a  feature 
in  many  of  the  predementia  praecox  signs,  and  one  cannot 
fail  to  be  impressed  by  the  unnatural  fatigability  of  these 
undividuals. 

Kahlbaum,  in  his  celebrated  monograph,  wrote  that 
he  had  been  struck  with  the  fact  that  so  many  teachers, 


Features  oj  the  Dementia  Praecox  Makeup         3 1 

sons  of  teachers,  theological  scholars,  have  been  affected 
by  the  katatonic  process.  He  believes  that  intellectual 
strain  is  one  of  the  foremost  of  the  contributory  causes 
to  this  type  of  breakdown,  abnormalities  in  the  sexual  life 
also  aiding. 

Illberg,  in  a  recent  monograph,  says  that  the  great 
majority  of  his  patients  were  hard  working  and  industrious. 
One  half  were  well  endowed,  the  others  less  so.  In  those 
of  less  marked  ability  a  protracted  mental  overstraining 
in  the  years  of  development  is  not  without  etiological 
significance.  Hecker  had  called  particular  attention  to  the 
backward  ones  who  were  unable  to  keep  up  in  their  develop- 
ment, and  Heller*^  has  dwelt  particularly  on  the  psychoses 
of  these  inferiors.  But  the  more  striking  instances  are  those 
who  have  been  precocious,  and  attention  should  be  carefully 
focused  on  the  precocious  children,  a  great  many  of  whom 
have  suffered  from  dementia  praecox. 

The  symptoms  that  develop  in  these  children  as  a  result 
of  overwork,  plus  other  factors,  concerning  which  we  are 
unable  accurately  to  estimate,  are  very  striking.  Certain 
forms  of  excitability  and  restlessness  should  be  distinguished 
from  the  ordinary  restlessness  and  general  tire  states  that 
are  normal  in  all  adolescent  schoolrooms.  The  patho- 
logical tire  is  one  that  does  not  recover  as  a  result  of  the 
usual  resting  period,  and  these  children  are  often  the  ones 
who  do  not  get  the  resting  period  because  of  a  certain 
intensity  of  their  application  to  their  work  or  to  reading.""* 
The  adept  teacher  recognizes  the  period  of  oncoming  fatigue 
by  the  marked  increase  in  mistakes  and  the  flagging  of  atten- 
tion. School  anxiety,  particularly  in  starting  new  work, 
is  to  be  carefully  studied,  either  as  a  sign  of  fatigue  or  as 
a  physiological  negativism  to  which  fatigue  has  given  birth 
as  its  corrective.  Changes  in  the  mood  are  of  much  mo- 
ment. Sudden  rudeness,  excessive  selfishness,  irritability 
and  peevishness,  lowery  quarrelsomeness,  often  indicate 
m.ore  than  the  normal  amount  of  fatigue,  and  are  often  the 
precursors  of  frank  mental  tire.'^ 

What  constitutes  this  mental  surmenage  does  not 
permit  of  clear  cut  definition.  It  shows  more  in  its  results 
than  in  the  making,  and  the  integer  of  most  importance 


32  Dementia  Praecox 

and  least  conspicuousness  Is  that  subtle  constitutional 
background.  The  amount  of  mental  work  seems  to  play 
less  role  than  the  method  of  its  acquirement.  Children 
well  trained  from  infancy  seem  to  stand  increasing  strains 
without  serious  embarrassment,  while  those  who  have 
had  little  or  no  training,  and  are  suddenly  called  on  for 
prolonged  cerebral  work  show  tendency  to  break  down  out 
of  proportion  of  what  might  be  expected.^^  Christian  and 
others  in  France  have  made  the  observation  that  when  an 
ill-directed  ambition  has  stimulated  children  of  psychically 
poor  rural  stock  to  take  up  intellectual  pursuits  in  the 
urban  centers,  dementia  praecox  is  not  an  infrequent  result. 

As  a  possible  illustration  of  this  latter  type,  the  strain 
of  a  city  life  imposed  upon  country  stock,  I  wish  to  detail 
the  history  of  a  case  in  which  I  have  been  able  for  more  than 
twenty  years  to  observe  the  patient  as  well  as  to  know  her 
family  and  surroundings.  It  may  serve,  also,  as  a  casuistic 
contribution  to  the  predementia  praecox  personality. 

History. —  The  patient  was  the  daughter  of  ambitious, 
well-read  people,  who  for  generations  had  lived  upon  a 
comfortable  farm.  The  mother,  a  merry,  clever,  witty, 
capable  little  woman,  the  father  an  earnest,  sentimental, 
religious  man  of  mediocre  business  abilities.  To  gain 
money  for  the  desired  education  for  the  family  of  five, 
the  father  went  to  New  York,  living  apart  from  his  family 
for  years,  while  the  mother  strained  every  nerve  to  clothe 
and  bring  up  the  children  well.  All  of  these  children  were 
talented,  ambitious,  and  keen  for  enlarged  opportunities. 
Finally  the  family  moved  to  the  city.  The  youngest  child, 
who  was  then  perhaps  eleven  years  of  age,  remembers  the 
leaving  of  the  farm  home  as  a  day  of  tragedy  for  herself, 
her  elder  sister,  and  her  mother,  but  a  day  of  emancipation 
for  her  ambitious  brothers,  and  the  sister,  who  afterwards 
became  my  patient. 

The  change  to  city  life  threw  an  undreamed  of  burden 
upon  the  whole  family.  The  mother  learning  for  the  first 
time  the  price  of  butter,  eggs,  vegetables,  and  chickens  and 
milk,  grew  worried  and  nervous  at  the  cost  of  mere  existence, 
let  alone  neighborly  hospitality.  Doing  one's  own  work 
in  the  city  was  an  infinitely  greater  strain  than  in  the  country. 


Features  of  the  Dementia  Praecox  Makeup         33 

The  elder  sister,  patient,  religious,  self-denying  almost  to 
the  point  of  martyrdom,  toiled  for  the  others  to  keep  the 
home  up  to  the  social  standard  of  what  they  wished  their 
position  to  be,  and  finally  succumbed  to  tuberculosis. 

One  son  became  a  journalist  and  wrote  successful 
verses.  He  married  a  talented  neurotic  woman,  who  when 
he  broke  down  nervously  went  on  with  his  work,  in  spite 
of  their  children,  until  she  herself  broke  down  and  died. 
His  nervous  collapse  then  became  very  serious,  but  fortu- 
nately he  was  advised  to  return  to  farm  life,  where  he  re- 
gained his  health,  and  was  able  in  some  measure  to  resume 
his  literary  work. 

Another  son,  who  began  his  career  as  an  artist,  and  who 
had  a  roving  year  or  two  on  sea  and  land,  that  built  up  his 
general  health,  entered  journalistic  work,  and  is  now  a  suc- 
cessful editor,  though  always  obliged  to  guard  against 
neurasthenia. 

The  younger  daughter,  who  was  more  shielded  from 
the  actual  burden  of  the  home,  and  whose  tuition  through 
college  was  provided  for,  was  able  to  bear  the  strain  of  later 
years,  and  gained  a  professorship  in  a  woman's  college. 

The  strain  upon  the  parents  culminated  when,  at  a 
change  of  administration,  the  father  lost  his  government 
position,  and  was  unable  to  earn  more  than  a  ver)^  small 
salary  at  uncongenial  employment.  The  death  of  the 
helpful  and  lovable  daughter  smote  the  mother,  and  she 
rapidly  declined,  having  nervous,  depressed,  and  apathetic 
attacks,  and  finally  became  demented  at  sixty-five.  The 
father  lived,  a  nervous  wreck,  for  many  years,  becoming 
senile  about  seventy-five. 

My  patient  was  the  second  daughter  of  the  family.  At 
the  time  of  the  breakdown,  which  finally  brought  her  to 
me,  she  was  about  thirty  years  of  age.  Her  wide  reading, 
a  knowledge  of  special  languages  and  literary  training  had  ♦ 
won  her  a  position  at  a  high  salary  in  a  college,  to  catalogue 
a  foreign  philosophical  library.  She  was  under  no  daily 
supervision  as  to  the  hours  or  the  quality  of  her  work  or 
her  social  life.  She  attended  a  great  many  lectures,  es- 
pecially those  on  psychology,  and  enjoyed  the  friendship  of 
many  families  of  the  faculty,  and  was  considered  a  clever 


34  Dementia  Praecox 

and    very    intellectual    girl.     Therefore,     her    apparently 
sudden  mental  collapse  came  as  a  shock  to  every  one. 

She  had,  during  the  two  years  previous  to  my  seeing 
her,  fallen  in  love  with  a  young  instructor  in  psychology, 
whom  she  made  legitimate  excuses  to  see  often.  She 
interpreted  every  word  he  spoke  with  a  double  meaning; 
so  that  while  he  was  conscious  only  of  being  formally  polite, 
she  was  building  up  an  elaborate  delusion.  She  believed 
the  college  had  chosen  her  particularly  alert  and  sensitive 
mind  to  work  out  a  psychological  test  to  see  whether  she 
would  read  his  love  through  signs.  Everything  worked 
into  the  grand  scheme,  the  signs  on  the  bulletin  board,  the 
hymns  in  chapel,  the  choice  of  the  subject  of  conversation 
at  a  faculty  party,  the  order  of  appearance  of  people  in  a 
room.  She  had  a  key,  a  sort  of  cryptogramic  arrangement 
of  letters,  by  which  she  re-read  all  communications.  Finally, 
she  confided  to  this  young  instructor  that  she  had  long 
comprehended  that  her  work  in  the  library  was  a  mere 
subterfuge  to  provide  her  a  position  while  the  college  ex- 
perimented on  their  psychological  unity,  and  to  his  bewilder- 
ment, she  assured  him  that  she  returned  the  love  he  had 
been  so  uniquely  expressing. 

Investigation  by  the  faculty  as  to  her  previous  mental 
state  revealed  that  although  occupying  her  desk  in  the 
library  she  had  been  irregular  in  hours,  and  had  done  very 
little  consecutive  work  for  some  months;  her  time  had 
been  spent  in  supposed  self-improvement,  attending  lec- 
tures and  making  out  this  key.  Comparison  of  conver- 
sations with  different  intimate  friends  showed  that  she  held 
unreasoning  enmity  against  certain  individuals  who  had 
been  unsympathetic  to  her  interests,  that  she  had  said  and 
done  many  peculiar  things,  and  that  she  was  given  to  fits 
of  abstraction  from  which  she  would  emerge  with  remarks 
totally  irrelevant  to  the  subject  of  conversation. 

The  loss  of  her  position  started  a  violent  train  of  sus- 
picions, which  gradually  assumed  more  definite  paranoid 
ideas  of  persecution,  in  which  all  those  she  held  as  enemies, 
^s  well  as  her  family,  were  involved. 

Her  family,  at  great  sacrifice,  sent  her  abroad,  but  she 
cherished  all  the  while  the  idea  that  the  young  man  had 


Features  of  the  Dementia  Praecox  Makeup         35 

induced  the  college  to  put  up  the  money  to  send  her,  in 
order  to  continue  the  psychological  experiment;  and  she  saw 
especial  adjustments  in  the  railroad  time  tables,  and  in 
signs  on  the  English  landscape,  that  indicated  that  the 
experiment  was  going  on,  and  her  anger  was  unbounded 
when  she  found  it  was  her  family's  money  which  had  been 
used. 

It  was  at  this  stage  that  I  began  to  see  her  profession- 
ally. She  was  suffering  from  insomnia,  very  nervous  and 
irritable,  super-sensitive,  seeking  a  sympathetic  ear  for 
her  delusional  ideas  and  great  aims  in  life,  but  became 
white  with  anger  when  they  were  criticized.  She  per- 
sisted in  attending  courses  in  psychology,  socialist  and 
philanthropic  meetings  whenever  she  could,  and  made  her- 
self a  nuisance  in  the  classes  by  urging  practical  reforms  and 
criticizing  existing  evils,  scoring  those  who  were  content 
with  talk  and  theories. 

She  was  so  intolerant  of  everything  in  her  family  life, 
from  the  time  meals  were  served,  to  the  number  of  children 
in  her  brother's  family,  that  she  would  harangue  all  her 
friends  on  these  subjects,  advancing  high  ethical  reasons 
for  all  her  vagaries. 

She  endeavored  to  get  a  light  library  position,  but  was 
incapable  of  any  systematic  or  sustained  work.  The 
presence  of  a  typewriter  machine  in  the  room  was  a  subject 
for  long,  high-flown  dissertations  on  silence  as  necessary  for 
concentration.  The  high  buildings  then  being  erected  near 
Columbia  so  occupied  her  that  she  tried  to  get  audience 
with  President  Low  and  public  officials  to  remonstrate 
with  them  on  the  subject.  She  lost  all  sense  of  time,  would 
make  a  call,  refuse  to  stay  to  dinner,  but  would  stay  on, 
then,  after  dining  abstractedly,  would  refuse  to  spend  the 
night,  but  would  nevertheless  remain  until  finally  induced 
to  go  to  bed.  She  lost  all  sense  of  money  obligation,  would 
borrow  and  use  money  needed  for  special  purposes.  She  lost 
all  reticence  and  became  so  distractible  that  she  could  not 
remember  where  any  of  her  possessions  were,  or  carry  out 
a  simple  consecutive  plan.  Through  all,  she  was,  however, 
pathetically  gentle,  lovable,  and  trusting  with  friends, 
except  with  her  family  or  those  who  aroused  her  antagonism. 


36  Dementia  Praecox 

She  was  always  borrowing  or  buying  deep  works,  in  which 
she  was  going  to  begin  a  course  of  reading  or  take  up  a  new 
language. 

As  her  letters  and  visits  to  public  men,  concerning 
vague  reforms,  became  more  frequent,  and  her  inability  to 
live  with  her  family  greater,  it  became  necessary  to  commit 
her.     During  the  last  ten  years  she  has  steadily  deteriorated. 

For  about  thirteen  years  previous  to  my  professional 
care  of  her,  I  had  known  the  patient  socially,  and  had 
noticed  traits  of  character  even  during  her  school  days 
which,  in  the  light  of  my  present  knowledge,  take  on  a 
significant  meaning.  These,  with  facts  carefully  ascertained 
from  her  family  and  intimate  friends,  show  the  early  pres- 
ence of  self-delusions  and  egoism,  and  lack  of  forceful  action, 
which  rendered  her  unable  to  bear  severe  strain  when  it 
came.  She  was  an  unusually  precocious  child,  and  evi- 
dently saw  herself  as  one  who  would  some  day  be  famous, 
for  she  used  to  relate  how  at  the  age  of  eight  she  would 
creep  under  the  table  to  read  Shakespeare  undisturbed, 
and  instead  of  laughing  at  the  list  of  grown-up  books  she 
had  read  at  twelve  years  of  age,  she  professed  to  be  pained 
at  the  juvenile  literature  offered  to  children.  She  was  very 
slight  and  frail  and  languid  in  her  movements.  She  was 
classically  beautiful,  and  had  a  wealth  of  hair  of  which  she 
was  vain.  She  was  very  fond  of  dainty  and  exquisite 
things,  but  so  little  able  to  satisfy  her  desires  that  her 
vanity  became  a  suppressed  affect,  and  she  would  criticize 
as  a  barbarian  any  girl  who  dressed  with  mere  money 
instead  of  taste.  She  spent  an  hour  each  morning  dressing 
her  hair  and  making  her  simple  toilet.  She  dropped  the 
remark  once  that  she  hoped  she  would  marry  while  her  hair 
was  still  beautiful.  At  home  she  demanded  that  no  house- 
hold cares  should  interfere  with  her  studies,  and  so  insistent 
was  her  will,  that  her  family  found  it  easier  not  to  cross  her. 
She  was  caustically  bitter  about  the  narrow  means,  in- 
efficient service,  and  let  the  unselfish  sister  cook,  sew,  and 
mend  without  help. 

At  school  she  was  gentle,  dreamy  in  manner,  and  re- 
cited in  a  lofty,  superior  way,  as  though  her  knowledge  of 
the  subject  went  far  beyond  the  text-books.     Some  thought 


Features  of  the  Dementia  Praecox  Makeup         37 

her  conceited  and  disdainful,  some  haughty  and  exclusive; 
others  thought  her  remarkable,  for  she  was  fond  of  talking 
with  the  professors  on  topics  beyond  the  ken  of  her  class- 
mates, perhaps  more  or  less  consciously  to  impress  them  with 
her  wider  knowledge.  Sometimes  she  calmly  stated  that 
she  was  unprepared  in  some  date  or  detail  of  history,  as  she 
had  not  opened  the  prescribed  text-book,  but  had  spent  the 
time  reading  a  more  profound  history  on  the  subject. 

When  others  received  better  marks  than  she,  she 
affected  to  despise  working  for  marks;  but  secretly  she  fed 
on  admiration  of  her  character,  and  found  some  cause  for 
contempt  in  any  one  who  excelled  her. 

At  seventeen  she  said  that  her  dearest  wish  was  to  be 
a  great  author  like  George  Eliot,  and  casual  remarks  in- 
dicated that  she  lived  in  a  day-dream  in  which  her  future 
was  filled  with  homage  and  glory.  She  was  easily  the  best 
writer  in  the  school,  doing  occasional  clever  verses  and  delicate 
charming  little  essays;  but  she  despised  the  means  to  attain 
her  desires.  Rules  of  rhetoric  she  held  were  self-evident, 
but  it  stultified  the  intellect  to  be  obliged  to  commit  them 
to  memory.  She  refused  to  send  in  preliminary  outlines 
of  her  essays  or  poems,  as  demanded  by  the  professor,  or 
else  prepared  caricatures,  with  elaborate  subtopics.  She 
once  delivered  an  eloquent  tirade  on  the  heinousness  of 
using  quotations  from  Shakespeare  for  the  class  to  analyze. 
She  seldom  wrote  essays  that  required  careful  reading  for 
facts;  and  if  such  were  imperative  they  were  long  overdue. 
Her  writing  showed  only  introspection,  and  never  the  result 
of  objective  observation.  When  her  period  of  deterioration 
came,  she  confessed  that  in  her  school  days  she  was  guilty 
of  plagiarism,  which  accentuated  the  hidden  desire  for 
admiration  which  she  always  cherished. 

She  was  satirical,  keen  in  pointing  out  people's  failings, 
and  bitter  to  any  one  who  did  not  take  her  at  her  own 
valuation.  She  once  attempted  to  organize  the  girls  of  the 
class  to  systematically  cut  a  certain  boy  who,  she  held,  had 
been  rude  to  them.  They  were  to  get  up  and  leave  the 
classroom  when  he  came  in.  Most  of  the  girls  didn't  see 
any  use  in  making  a  fuss,  and  the  snub  fell  through,  to  her 
open    vexation.     Very   occasionally  the  temper  which  she 


38  Dementia  Praecox 

frequently  showed  at  home  flashed  out  at  school,  and  she 
once  actually  shook  her  best  friend,  for  suggesting  that  they 
should  both  finish  preparing  a  lesson  before  going  out  in 
the  woods  with  a  book  of  poems.  "Have  you  no  feeling 
for  the  beauty  and  inspiration  of  the  woods,  that  you  must 
sit  indoors  and  commit  those  stupid  Anglo-Saxon  de- 
clensions," she  said,  and  she  snatched  the  book  away  and 
never  prepared  the  lesson. 

Her  school  intercourse  was  full  of  such  sophisms,  all 
bearing  on  the  value  of  originality  over  the  acquisition  of 
facts,  and  showing  her  precociousness  in  book  lore,  but 
her  lack  of  observation.  It  might  also  have  been  owing  to 
her  lack  of  attention  to  external  impressions  that  while  she 
could  read  several  languages,  and  was  a  good  Latin  scholar, 
she  could  not  speak  or  understand  a  foreign  language  with 
ease.  (This,  however,  is  such  a  common  result  of  school 
education  as  hardly  to  reflect  on  her  personal  weakness  in 
auditory  impressions.) 

She  was  frequently  lost  in  abstraction,  often  would  not 
answer  when  spoken  to,  as,  for  instance,  when  a  friend 
told  her  with  great  enthusiasm  that  she  was  going  to  Europe, 
she  received  the  news  in  silence,  walked  on  for  some  blocks 
without  speaking,  and  then  apologized  contritely  and  said, 
"Excuse  me,  but  did  you  say  something  about  Europe —  I 
was  thinking  of  something  for  the  moment." 

Until  the  time  she  left  school  her  egoism  and  day- 
dreaming meant  no  more  than  they  would  in  the  average 
girl;  and  had  her  family  been  well  to  do,  and  her  envied 
social  position  surely  established,  her  ambitions  possibly 
would  not  have  developed  such  strong  emotional  complexes. 

Her  father's  loss  of  position  occurred  shortly  after  she 
graduated;  and  the  family  troubles  began. 

She  heroically  threw  herself  into  the  breach,  getting 
some  journalistic  work  to  do,  and  soon  entered  upon  library 
work;  always  with  the  idea  that  she  was  literary  and  going 
to  write. 

She  helped  to  contribute  to  her  sister's  college  course, 
and  was  subject  to  all  the  anxieties  of  the  home  for  some 
years.  Here,  imperceptibly,  the  break  must  have  begun. 
She  began  to  attribute  her  not  writing  to  her  lack  of  a 


Features  oj  the  Dementia  Praecox  Makeup  39 

college  education,  and  was  constantly  taking  up  some  out- 
side course,  on  which  she  worked  in  an  inefficient  manner, 
always  finding  fault  with  what  she  considered  the  un- 
necessary drudgery  of  it.  She  resigned  a  good  position  for 
no  reason  but  that  she  felt  the  superior  did  not  like  her; 
and  uttered  one  of  the  remarks  that  she  often  made  in  the 
next  years,  "He  never  said  anything,  but  if  you  had  noticed 
all  the  trifling  things  that  happened  you  would  have  been 
able  to  put  two  and  two  together  and  understand."  When 
her  superior  expressed  his  surprise  at  her  resignation,  she 
quoted  with  contempt  his  questions  as  to  her  reasons,  and 
his  hope  that  she  would  reconsider  it,  leaving  her  friends 
to  infer  that  he  knew  perfectly  well  the  reason,  and  was  only 
affecting  surprise. 

So  many  of  these  unexplained  moves  occurred,  for 
which  she  could  give  no  common-sense  reason,  that  it  is 
probable  her  introspection  was  becoming  far  stronger  than 
external  influences,  and  that  she  was  living  in  a  world  of 
dreams  in  which  she  was  fitting  her  own  interpretation  to 
the  most  commonplace  facts. 

As  far  as  I  could  learn  her  sexual  tendencies  were 
psychic  in  their  nature  rather  than  physical.  She  desired  the 
admiration  and  intellectual  sympathy  of  men,  although  she 
showed  such  marked  contempt  for  the  crude  youth  of  her 
own  age,  that  she  received  but  little  attention.  I  am  led 
to  think  this  lack  became  an  affect,  for  she  pretended  to 
despise  all  attentions,  while  nevertheless  cherishing  the 
remarks  of  older  and  cultivated  men. 

A  little  later,  between  the  years  perhaps  of  twenty-five 
and  twenty-six,  there  occurred  the  first  love  affair  in  which 
her  delusional  ideas  became  somewhat  systematized. 

She  met,  at  a  library  convention,  an  interesting  man, 
with  a  marked  physical  infirmity,  who  paid  her  some  atten- 
tion and  to  whom,  in  order  to  put  him  at  ease,  she  showed 
herself  more  cordial  than  was  her  wont.  He  was  clever,  and 
she  exerted  herself  to  be  entertaining,  with  the  result  that 
in  parting  they  began  a  correspondence,  and  he  called  to 
see  her  at  rare  intervals,  when  in  New  York.  By  the  time 
they  met  again,  at  a  second  convention,  she  read  a  meaning 
in  all  he  did.     He  was  on  the  committee  of  arrangements. 


40  Dementia  Praecox 

and  the  selections  of  music,  the  colors  of  the  bunting  in 
decoration,  and  even  the  menu  of  the  reception  supper  were 
all  carried  out,  she  felt,  in  response  to  subtle  suggestions 
of  her  own;  or  to  please  her  formerly  expressed  tastes. 
Her  sister  and  the  intimate  friends  to  whom  the  confided 
the  details  of  this  wonderful  journey,  confessed  that  they 
could  see  no  symbolism  in  olives,  nor  in  popular  band  music, 
and  she  would  answer,  with  almost  fiery  impatience,  "Of 
course  it  doesn't  seem  the  same  when  you  express  it,  but 
if  you  had  been  there,  and  heard  his  tone,  or  seen  the  way 
he  looked."  She  felt  that  he  understood  that  his  infirmity 
glorified  him  in  her  eyes,  and  that  they  were  extremely 
sympathetic. 

After  this,  she  suffered  at  his  long  silences,  inquiring 
of  her  confidants  what  they  could  mean.  To  all  outward 
evidences,  it  was  a  purely  casual  acquaintance,  and  yet  her 
feeling  of  sympathetic  communication  was  so  strong  that 
when  in  a  chance  note  he  remarked  that  his  business  would 
take  him  to  Chicago  frequently,  she  took  it  as  a  desire  that 
she  should  go  to  Chicago  to  live.  She  accordingly  obtained 
an  excellent  position  in  one  of  the  large  libraries,  and  pre- 
pared a  little  home  and  social  circle  to  receive  him.  The 
time  was,  however,  very  long  between  visits,  and  her  ac- 
quaintance with  mutual  friends  showed  her  that  he  did  not 
always  come  to  see  her  when  in  town.  Finally,  one  day, 
without  warning,  she  received  his  wedding  announcements. 
Her  state  of  mind  was  then  plainly  revealed.  She  felt  he  had 
been  deceiving  her,  or  else  was  the  victim  of  a  plot.  She 
wrote  to  him  at  once,  returning  a  package  of  his  few  treas- 
ured notes,  and  demanded  that  he  should  return  hers. 
He  replied  that  he  regretted  that  he  had  never  kept  any  of 
her  notes,  and  said  if  he  had  in  any  way  caused  her  pain 
he  regretted  and  apologized.  She  believed,  however,  that 
he  had  the  notes,  and  that  there  was  a  tangled  plot  to  un- 
ravel. It  was  impossible  for  her  to  accept  the  fact  as  her 
friends  had  seen  it,  that  he  was  merely  a  polite  acquaintance, 
and  for  a  time  she  was  greatly  chagrined,  but  kept  matters 
pretty  well  to  herself. 

Losing  all  interest,  however,  in  Chicago,  where  she  had 
been  sustained  by  this  slender  hope,  she  accepted  the  posi- 


Features  oj  the  Dementia  Praecox  Makeup        41 

tion  of  expert  cataloguer  in  the  psychological  library  I 
first  spoke  of,  and  in  the  stimulus  of  new  faces  forgot  her 
first  affair,  and  began  the  second  one-sided  romance.  It 
naturally  was  but  a  continuation  of  the  same  mental  habit 
of  ignoring  realities  and  building  pictures,  but  with  a  differ- 
ent hero. 

It  is  interesting  to  note  that  her  three  strong  affects  have 
continued  through  her  hospital  confinemant,  viz.,  her  desire 
to  pursue  advanced,  chiefly  psychological  studies,  her  belief 
that  she  has  a  secret  affinity  with  some  man,  and  her  belief 
that  she  has  literary  power. 

I  believe  that  at  any  time  through  her  school  years, 
and  up  to  twenty  years  of  age,  there  were  sufficient  signs 
to  warn  the  modern  psychiatrist  of  danger,  and  also  sufficient 
time  to  have  saved  her,  could  she  have  been  relieved  of  the 
overstrain,  and  could  have  had  a  life  plan  made  out  that 
would  deal  with  objective  interests. 

I  have  no  time  in  this  discussion  to  attempt  to  present 
an  analysis  of  the  many  features  that  this  bare  recital  has 
suggested,  but  throughout  we  find  the  day  dreaming  with- 
out efficient  activity,  an  accentuated  ego  complex  with  its 
maladjusted  attempts  at  compensation,  and  particularly 
prominent,  especially  in  the  two  love  affairs,  there  appears 
the  emotionally  accentuated  love  complex''^  which  later 
seemed  to  play  so  important  a  part  in  the  expressed^symp- 
tomatology  (complex  expression).  Viewed  in  the  light 
of  perverse  adjustments  to  constantly  recurring  difficulties, 
much  of  her  conduct  is  explicable.  An  extensive  psy- 
choanalysis by  the  Zurich  School  methods  would  undoubt- 
edly fill  in  most  of  the  gaps,  but  my  observations  were  made 
at  a  time  when  these  methods  had  not  arisen.  The  patient 
is  still  accessible,  and  would  undoubtedly  repay  psycho- 
analysis. 

I  am  unprepared  to  accept  the  Freudian  hypothesis 
that  the  complex  —  or  group  of  complexes  —  of  themselves 
are  sufficient  to  develop  the  disease  in  all  of  its  phases.  The 
present  case  may  be  regarded  as  a  type  wherein,  if  there  be 
truth  in  this  general  view,  a  good  illustration  may  be  looked 
for,  for  the  entire  development  of  the  disease  has  followed 
along  the  line  of  a  few  accentuated  complexes.     It  strikes 


42  Dementia  Praecox 

me  that  Bleuler's  position  in  this  matter,  however,  is  well 
taken,  that  the  complex  does  not  cause  the  disease,  but  may 
determine  its  symptomatology.  In  this  respect  he  rejects 
the  ultra-Freudian  views  of  which  it  would  appear  A.  Meyer 
is  an  advocate. 

To  posit  certain  character  anomalies  and  varieties  of 
personality,  as  fundamental  for  certain  psychoses,  is  no  new 
standpoint,  rather  one  can  say  on  viewing  the  history  of 
human  endeavor,  that  it  is  a  very  old  idea,  and  one  that 
instead  of  receiving  even  the  warmth  of  approval  has  gone 
through,  in  recent  years,  the  cold  shoulder  period,  and  has 
been  almost  tabooed  as  a  charlatanistic  catch  penny.  In  the 
very  early  days  mental  disturbances  were  all  referred  to 
the  personality  and  thought  of  in  terms  of  exaggerated 
distorted  characteristics.  Even  so  late  as  the  time  of 
Morel  one  sees  this  feature  magnified,  and  with  him  one 
finds  practically  but  one  psychosis  with  the  different  colora- 
tions and  variations  due  to  personal  character  peculiarities. 
A  corresponding  moral  therapy  one  can  see  in  its  most 
classical  form  in  Heinroth  and  his  immediate  predecessors. 
Naturally  with  the  anatomical  era  of  Bayle,  of  Falret,  of 
Griesinger,  of  Meynert,  and  of  Alzheimer,  the  personal 
character  anlage  conception  has  been  retired  to  the  back- 
ground, and  our  interpretations  of  the  psychoses  have 
become  more  and  more  interwoven  with  conceptions  of  or- 
ganic alterations.  Perhaps  the  time  has  come  to  strike 
a  balance  and  to  consider  the  question  whether  at  least 
certain  psychoses  may  not  be  interpreted  more  from  the 
functional  side.  Certainly  the  masterly  studies  of  individual 
psychology  and  their  appHcation  to  the  problems  of  psy- 
chiatry as  evidenced  in  the  work  of  Freud  and  his  followers, 
Bleuler,  Jung,  Maeder,  Meyer,  and  others,  are  offering 
much  suggestive  light  upon  this  aspect  of  the  question. 
Our  enthusiasm  in  having  a  new  viewpoint  should  not, 
however,  lead  us  to  an  uncritical  acceptance  of  these  ultra- 
Freudian  studies.  Certainly  the  views  of  Gross  relative 
to  manic  depressive  psychoses  are  far  from  the  mark.  The 
criticisms  of  E.  Meyer,  Weygandt,  Isserlin,  Friedlander, 
Kraepelin,  and  others,  deserve  careful  weighing  before  we  are 
swept  from  our  feet  by  the  attractive  generalizations  of  the 
Freudian  School. 


Features  of  the  Dementia  Praecox  Makeup         43 

In  any  attempt  to  analyze  the  dementia  praecox  character 
it  seems  advisable  at  the  outset  to  limit  ourselves  somewhat 
within  the  nosological  conception  of  the  group.  In  making 
such  a  limitation,  the  broad  question  of  constitutional 
defect  first  obtrudes  itself,  and  we  must  eliminate  at  once 
those  in  whom  congenital  defects,  usually  termed  "the 
high-grade  imbecile  group,"  exists.  Naturally  only  the 
minor  grades  of  feeble-mindedness  will  attain  any  diagnostic 
significance,  so  far  as  differentiation  is  concerned. 

Further,  due  attention  must  be  paid  to  the  aberrancies 
of  the  katatonic  group.  Whether  we  are  as  yet  prepared 
to  accept  a  special  cerebellar  katatonic  type,  as  posited 
by  L'Hermitte,  by  Claude,  and  by  a  number  of  other  workers, 
it  seems  positive  that  defective  or  diseased  cerebellar 
mechanisms  can  give  rise  to  a  very  marked  degree  of  kata- 
tonic coloring,  and  it  may  be  advisable  to  eliminate  those 
cases  which,  from  a  clinical  standpoint,  may  be  shortly 
correlated  with  the  special  pathological  features  of  certain 
cerebellar  function  defects.  I  would  not  argue  the  aboli- 
tion of  all  of  the  cases  with  strong  katatonic  coloring.  Many 
no  doubt  represent  purely  functional  cleavages,  and  are 
properly  included  in  our  special  group,  still  the  fact  that 
many  call  for  organic  interpretation  should  sharpen  our 
diagnostic  criteria. 

In  the  time  at  my  disposal,  further  indications  of  types 
that  may  be  eliminated  must  be  passed  over  —  suffice  it 
to  say  that  there  are  a  number  of  others,  and  that  numerous 
studies  have  appeared  which  tend  to  give  foundation  to  the 
rationale  of  definite  subgroups  within  the  katatonic  syn- 
drome, more  particularly  which  would  eliminate  those 
particular  cases  from  consideration,  so  far  as  our  present 
viewpoint  is  concerned. 

It  is  furthermore  certain,  that  many  cases,  which  in 
the  earlier  days  of  Kraepelin's  teachings  were  regarded  by 
him  and  by  his  students  as  "schoolroom"  cases  of  katatonia 
have  turned  out  quite  different  from  what  was  expected. 
They  have  either  later  showed  typical  manic  attacks  or 
have  recovered  and  remained  well  for  many  years.  A 
tendency  to  lay  too  much  stress  upon  a  single  prominent 
feature  has  involuntarily  produced  a  one-sided  estimation 
of  these  so-called  katatonics. 


44  Dementia  Praecox 

Many  paranoid  cases  also  must  be  eliminated  from  the 
praecox  group  and  relegated  to  other  domains.  The  bound- 
aries are  still  very  fluctuating  and  hazy,  but  in  the  group 
of  the  so-called  prison  or  detention  paranoid  praecox  cases, 
new  criteria  must  be  employed.  Certain  paranoid  cases 
certainly  have  close  alliances  with  the  constitutional  ex- 
citements and  hence,  with  Specht  and  others,  we  must 
group  them  with  the  general  manic  depressive  series. 

Admitting  that  this  paring  process  will  take  place 
precisely  as  it  has  taken  place  in  all  other  branches  of 
medicine,  and  that  we  may  ultimately  arrive  at  the  com- 
paratively pure  praecox  cases,  we  are  then  in  a  position  where 
casuistic  contributions  to  the  subject  of  a  predementia 
praecox  personality  will  be  of  service  to  us.  It  is  admitted 
that  we  have  not  yet  arrived  at  such  a  point,  but  this  does 
not  prevent  us  from  attempting  a  summary  of  what  striking 
features  do  appear  in  the  histories  of  those  who  later  have 
broken  down  in  a  manner  broadly  indicative  of  the  group, 
not  as  it  needs  to  be  limited,  but  as  it  has  been  generally 
understood. 

But  few  have  busied  themselves  with  this  problem 
within  the  specified  lines  of  our  inquiry.  What  facts  and 
conjectures  we  have  come  from  Kahlbaum,  Hecker,  from 
Kraepelin  himself,  from  Paulhan,  Hall,  Meyer,  Mingazinni, 
Hoch,  and  Kirby.  My  own  contribution  did  hardly  more 
than  raise  the  question  which  had  already  been  well  handled 
from  another  viewpoint  by  Meyer. 

In  Meyer's  paper  published  in  the  Journal  of  American 
Psychology,  Vol.  XIV,  entitled,  "An  attempt  at  Analysis 
of  the  Neurotic  Constitution,"  he  describes  the  deteriorating 
type  as  follows: 

"In  cases  of  dementia  praecox  we  find  over  and  over,  an 
account  of  frequently  exemplary  childhood,  but  a  gradual 
change  in  the  period  of  emancipation.  Close  investigation 
shows,  however,  often  that  the  exemplary  child  was  exem- 
plary under  a  rather  Inadequate  ideal,  an  example  of  goodness 
and  meekness,  rather  than  of  strength  and  determination, 
with  a  tendency  to  keep  to  the  good  in  order  to  avoid  fights 
and  struggles.  Later,  religious  interest  may  become  very 
vivid,  but  also  largely  In  form;  a  certain  disconnection  of 


Features  of  the  Dementia  Praecox  Makeup         45 

thought,  unaccountable  whims  make  their  appearance, 
and  deficient  control  in  matters  of  ethics  and  judgment.  At 
home  irritability  shows  itself,  often  wrapped  up  in  moral- 
izing about  the  easygoing  life  of  brothers  and  sisters. 
Sensitiveness  to  allusions  to  pleasures,  health,  etc.,  drive 
the  patient  into  seclusion.  Headaches,  freaky  appetite, 
general  malaise,  hypochondriacal  complaints  about  the 
heart,  etc.,  unsteadiness  of  occupation  and  inefficiency,  day 
dreaming,  and  utterly  immature  philosophizing,  and  above 
all  loss  of  directive  energy  and  initiative  without  obvious 
cause,  such  as  well-founded  preoccupations,  except  the 
inefficient  application  to  actuality.  All  these  traits  may 
be  transient,  but  are  usually  not  mere  'neurasthenia,' 
but  the  beginning  of  a  deterioration,  more  and  more  marked 
by  indifference  to  the  efnotlonal  life  and  ambitions,  and  a 
peculiar  fragmentary  type  of  attention,  with  all  the  transi- 
tions to  the  apathetic  state  of  terminal  dementia."    = 

This  same  author  in  the  Psychological  Clinic  (Vol. 
II,  No.  4),  in  an  article  entitled  "What  do  Histories  of  Cases 
of  Insanity  Teach  us  Concerning  Mental  Hygiene  During 
the  Years  of  School  Life.?"  makes  the  following  observations: 

"Looking  over  the  records  of  sufficiently  studied  cases, 
I  find  that  the  children  who  later  developed  abnormal 
reaction  of  the  type  of  dementia  praecox  were  peculiar  rather 
than  defective  in  the  senses  which  we  have  in  mind  when  speak- 
ing of  those  who  are  backward  or  retarded.  Furthermore,  I 
find  that  as  a  rule  we  are  concerned  less  with  aggressive 
mischief  than  with  repressive,  and  what  Is  at  times  charac- 
terized as  'depth  of  thought.'  The  children  affected  are 
the  very  ones  whom  a  former  generation  might  have  looked 
upon  as  'model  children.'"  He  continues:  "A  considera- 
tion of  carefully  studied  cases  of  dementia  praecox  convinces 
me  that  In  reality  we  have  to  do  with  a  perfectly  natural, 
though  perhaps  unconsciously  persistent  development  of 
tendencies  difficult  to  balance."  The  common  tendencies 
of  adolescence,  such  as  a  reading  craze  in  some  children, 
day  dreaming  In  others,  or  abnormal  sexual  practices,  are 
usually  offset  In  one  way  or  another  by  the  more  natural 
and  sociable  children.  To  others,  however,  the  very  habits 
of  the  patient,  the  loss  of  sense  for  the  real  and  the  abnormal 


46  Dementia  Praecox 

satisfaction  in  dreaming  and  good  resolutions,  encourage 
a  mere  dodging  of  the  consequences  rather  than  giving  up  the 
harmful  instincts.  Those  who  fail  are  irritated  by  their 
disadvantage  with  others,  and  try  to  cover  up  rather  than 
correct  their  harmful  yearnings.  "There  develops  an  in- 
sidious tendency  to  substitute  for  an  efficient  way  of  meeting 
the  difficulties,  a  superficial  moralizing  and  self-deception, 
and  an  uncanny  tendency  to  drift  into  so  many  varieties  of 
shallow  mysticism  and  metaphysical  ponderings,  or  into 
fantastic  ideas  which  cannot  possibly  be  put  to  the  test 
of  action. 

"All  this  is  at  the  expense  of  really  fruitful  activity, 
which  tends  to  appear  as  insignificant  to  the  patient  in 
comparison  with  what  he  regards  as  far  loftier  achievements. 
Thus  there  is  an  ever-widening  cleavage  between  the  mere 
thought  life,  and  the  life  of  actual  application,  such  as  would 
bring  with  it  the  corrections  found  in  concrete  experience. 
Then  under  some  strain  which  a  normal  person  would  be 
prepared  for,  a  sufficiently  weakened  and  sensitive  indi- 
vidual will  react  with  manifestations  which  constitute  the 
mental  disorders  constituting  the  'deterioration  process,' 
or  dementia  praecox.  Unfinished,  or  chronically  sub- 
efficient  action,  a  life  lived  apart  from  the  wholesome  in- 
fluence of  companionship,  and  concrete  test,  and  finally  a 
progressive  incongruity  in  meeting  the  inevitably  complex 
demand  of  the  higher  instincts,  this  is  practically  the  formula 
of  the  deterioration  process."        '  .^ 

This  very  admirable  outline  of  the  progressive  steps 

y   by   which   natural   and   almost   normal  tendencies  become 

if  abnormal   emphasizes    the   necessity   for   getting   full   and 

\*     circumstantial  early  histories  in  all  these  cases  oft  dementia 

■>iV  praecox;  for  I  hold  that  much  can  be  done  to  lift  the  burden 

r^iof  failure,  to  relieve  the  brooding  over  incapacity,  at  a  mo- 

v  ^,  '^  ment  in  the  life  of  a  youth,  by  giving  the  prospective  patient 

^  ^  '^  something  to  do  which  he  can  do  well,   and    by  making 

\\    I  interesting  concrete  work,  often  manual  work  to  cut  short 

^'^  '  ^  the  pernicious  day  dreaming  that  mere  bookwork  permits, 

*  ^    and  also  by  selecting  a  walk  of  life  more  suited  to  the  pa- 

'     tient's  real  capacities  than  that  to  which  he  vaguely  aspires. 

In  collecting  histories  of  the  predementia  praecox  state. 


Features  of  the  Dementia  Praecox  Makeup        47 

one  of  the  chief  points  to  be  noted  is,  Was  the  patient  able 
to  adequately  fill  small  demands,  and  did  he  fail  under  the 
heavier  strain.  If  so,  under  what  strain?  Was  he  helped 
to  meet  the  greater  demands,  or  did  he  suffer  shame  and 
brood  over  his  failure?  Again  note.  Did  the  patient  find 
difficulty  in  translating  thought  into  action? 

In  his  dynamic  interpretations  of  dementia  praecox, 
Meyer'^  reiterates  his  functional  view,  giving  it  even  greater 
precision  than  heretofore.  He  regards  the  Kraepelian 
standpoint  as  formal,  empirical,  and  dogmatic.  His  factors 
are  dynamic  and  stand  out  in  certain  activities  and  states 
of  disturbed  balance  and  regulation  which  have  far- 
reaching  effects  upon  the  mental  adjustments  themselves, 
and  incidentally  upon  the  organic  understructure  of  the 
personality. 

Specific  defects  or  disorders  of  balance,  with  special 
tendencies  and  habitual  ways  of  bungling  and  substitutions, 
and  a  special  makeup  liable  to  break  down  in  a  specific 
manner  —  these  are  all  assumed  by  Meyer,  and  opposed 
by  him  to  the  various  toxic  factors  postulated  in  the  organic 
hypotheses  of  other  observers.  >  Starting  with  his  Toronto 
address  as  the  first  formulation  of  views,  Meyer  elaborates 
his  idea  of  the  gradual  maladjustments  that  come  about 
through  the  ever-increasing  intricacies  of  at  first  harmless 
substitutions  and  subterfuges  until  they  become  harmful 
and  uncontrollable. 

The  katatonic  syndrome,  Meyer  is  inclined  to  believe, 
may  yield  to  a  psycho-biological  interpretation  and  to 
psycho-analysis.  No  discussion  of  the  makeup  in  these 
individuals,  beyond  a  short  reference  to  Hoch's  term  "shut 
in  personality"^"  already  utilized  in  part  by  Hecker,  is 
found  in  this  extremely  interesting  paper,  but  the  thera- 
peutic mode  of  attack  assumes  much  more,  and  should  be 
emphasized.  He  says:  "Where  a  break  or  morbid  reaction 
has  once  set  in  it  is  very  difficult  to  bring  relief  directly. 
The  fundamental  shutting  in  of  the  whole  mechanism  en- 
ables the  pre-occupations  to  live  themselves  out  and  to 
exclude  interference.  Automatic  resistance  against  the 
most  natural  impulses  frustrate  even  the  occasional  pathetic 
spontaneous   appeals   of  the   patient   for   help.     The   best 


48  Dementia  Praecox 

procedure  Is  to  tide  over  the  acute  tangle  with  as  much 
tact  and  ease  as  possible,  to  promote  relaxation,  and  to 
relieve  the  situation  wherever  that  can  be  done,  bearing 
in  mind  the  facts  obtained  referring  to  the  upsetting  factors, 
the  probable  complex-constellations  and  prevailing  phy- 
sical disorders.  As  soon  as  the  patients  feel  that  they  meet 
with  help  instead  of  an  argumentative  and  corrective 
attitude,  they  can  be  led  considerably  when  the  time  comes 
or  where  the  difficulty  has  not  led  to  complete  blocking. 
Then  a  positive  re-education  in  the  form  of  habit-training 
and  of  readjustment  has  to  set  in.  It  is  obvious  that  ex- 
perience brings  a  certain  divination  and  that  individual 
capacity  plays  a  decided  role  in  the  straightening  out  of 
the  difficulties,  both  during  the  tangles  and  in  ultimately 
marshalling  the  forces  to  a  more  practical  unity  and  level 
again;  it  is  also  obvious  that  we  cannot  be  very  optimistic 
in  most  cases,  as  Httle  as  when  we  try  to  win  over  our 
less  unbalanced  neighbors  to  a  better  mode  of  thought, 
belief,  conduct,  and  behavior. 

My  own  observations  of  patients  whom  I  have  known  ) 
intimately  since  childhood  have  shown  that  the  paranoid  ) 
dement  in  particular  has  been  rather  abnormally  brilliant,  \ 
but  with  the  lights  turned  inward  rather  than  outward.  * 
They  were  extremely  unpractical  in  the  use  of  their  hands, 
or  in  any  adaptation  to  material  ends.     They  were  utterly 
unable  to  observe  with  accuracy  anything  physical  or  ma- 
terial, for  their  minds  were  constantly  turned  in  upon  their 
own  meditations.     They  were  all  unready  to  adapt  them- 
selves to  uncongenial  environment.     I  do  not  mean  the  en- 
vironment of  personal  discomfort.     This  they  often  ignored, 
but  they  revolted  against  the  environment  of  other  minds, 
of   imposed  regulations,  or  of    standards  of    requirements. 
They  were  subject  to  fits  of  abstraction,  when  they  would 
not  hear  or  see  what  would  attract  a  normal  youth.     They 
were  usually  irritable  to  their  families,  but  most  desirous 
of  being  thought  either  amiable  or  brilliant  by  strangers. 
They  were  abnormally  sensitive  and  suspicious,  and  most 
were  prone  to  discuss  deep,  unsolvable  questions. 

No  one  of  these  traits  alone,  or  even  in  small  groups, 
causes  a  danger  signal,  but  when  any  or  all  are  combined 


Features  oj  the  Dementia  Praecox  Makeup        49 

with  the  inability  to  bring  oneself  in  touch  with  the  physical 
world,  with  a  constitutional  aversion  to  deeds,  and  a  glori- 
fication of  vague  abstractions,  it  is  justifiable  to  regard  the 
child  or  youth  as  a  patient,  and  to  so  adjust  his  level,  and  to 
train  him  to  be  interested  in  his  small  demands  so  that  he 
may  be  saved  the  necessity  of  meeting  greater  demands  than 
his  capacity  can  bear. 

REFERENCES 

1.  Salz,  Rev.  Sper.  d.  Fren.,  33, 1907,  p.  364. 

la.  Weber.   Die  Pathogenese  und  pathologische  anatomie  der  Geisterstorungen. 
Ergebnisse  der  allg.  Path.  13,  1909.  II.  623. 

2.  Am.  Jl.  Med.  Sciences,  Aug.,  1907. 

3.  Wagner  v.  Jauregg,  Einiges  uber  erbliche  Belastung,  Wien  klin.  Woch.,  19, 

1906,  1. 

4.  Roller,  Arch.  f.  Psych.     1895,  27,  p,  268. 

5.  Diem,  Arch.  f.  Rassen  v.  Gesells.  Biol.,  1905.       2,  p.  336. 

6.  Munch,  med.  Woch.,  1901,  Nos.  45,  46;  Allg.  Z.  f.  P.,  61. 

7.  Allg.  Z.  f.  P.,  24,  1907. 

8.  Mayet,  Jahrb.  fl.  int.  Vereinigung  f.  vergl.  Rechtswissenschaft  in  Volktwi*- 

senschl..  Vols.  6,  7. 

9.  Lehrbuch,  Seventh  edition. 

10.  Monograph,  1907. 

11.  Text-Book. 

12.  Text-Book. 

13.  Allg.  Z.  f.  P.,  61, 1904,  365. 

14.  Allg.  Z.  f.  P.,  62, 1905,  230. 

15.  J.  N.  &  M.  D.,  1904. 

16.  Allg.  Z.  f.  P.,  60,  1903,  224. 

17.  Monats.  f.  P.  &  N.,  9,  1901,  p.  161. 

18.  Arch.  f.  P.,  16,  1885, 113. 

19.  Obersteiner's  Arbeiten,  15,  1907,  282. 

20.  Allg.  Z.  f.  P.,  64, 1907,  347. 

21.  Allg.  Z.  f.  P.,  64,  1907,  176. 

22.  Centralblatt  f.  N.u.P.,  32, 1909, 877,  also  Inaugural  Dissertation,  Freiburg,  1910. 

23.  Ueberburdungspyschosen    bei    minderwertigen    Kindern,    Zeits.    f.    Schul- 

gesundheitspfiege,  19,  1905,  p.  649. 

24.  Spitzner,    Anzeichen    beginnender   Nervositat,   Zeitschrift   f.    Schulgesund- 

heitspflege,  16,  1903,  p.  395. 

25.  Hintz,  Geistessorungen  unter  den  Schulkindern,  Zeitschrift  f.  Schulgesund- 

heitspflege,  1899,  p.  179. 

26.  Wille,  Die  Psychosen  des  Pubertatsalters,  1902. 

27.  Jung,  Psychology  of  Dementia  Praecox,  "Nervous  and  Mental  Disease  Mono- 
graph Series,"  No.  3,  New  York,  1909. 

28.  Am.  Jl.  Psych.,  21,  1910,  385. 

29.  Berze.     Die  hereditaren  Beziehungen  der  Dementia  praecox.  1910. 


50  Dementia  Praecox 

29.  Die  hereditaren  Beziehungen  der  Dementia  Praecox.  Beitrag  zur  Heredi«^ 
tatalchre.     1910. 

30.  A.  Hoch.  Constitutional  Factors  in  the  Dementia  Praecox  Group.  Rev.  of 
Neurology  and  Psychiatry,  8, 1910,  p.  463 .  Gjntains  a  formulation  of  his  views 
as  to  what  constitutes  the  "shut-in  personality."  No  credit  is  given  by  Hoch  to 
Hecker  who  first  speaks  of  these  patients  as  "Verschlossen."  See  Jelliife, 
Dementia  Praecox.    A  Historical  Summary.  N.  Y.  Med.  Jour.  March,  1910. 


ON   SOME   OF  THE   MENTAL    MECHANISMS   IN 
DEMENTIA  PRECOX 


ON    SOME   OF   THE   MENTAL   MECHANISMS    IN 
DEMENTIA   PRiECOX 

BY   AUGUST   HOCH,    M.D. 

Psychiatric  Institute,  New  York  State  Hospitals 

IN  this  symposium  I  have  been  asked  to  take  up  the 
symptomatology  of  dementia  praecox  from  the  point 
of  view  of  the  content  of  the  psychosis.  It  is, 
therefore,  not  within  my  province  to  dwell  either  on  the 
general  principles  of  the  disorder,  or  the  constitutional 
factors  which  play  such  an  important  part  in  these  cases.f 
My  task  is  rather  to  state  briefly  what  a  study  of  the  con- 
tent of  the  psychosis  seems  to  indicate. 

In  certain  simple  paranoic  states,  or  in  a  certain  type 
of  psychoses  of  degenerates  to  which  BirnbaumJ  has  re- 
cently devoted  a  monograph,  it  can  scarcely  be  questioned 
that  the  content  of  the  psychosis  represents  conflicts  and 
reactions  to  conflicts  which  the  individual,  owing  to  an 
inherent  constitutional  deficiency,  has  been  incapable  of 
handling  adequately.  In  cases  in  which  we  are  able  to 
analyze  the  symptom  picture  of  dementia  praecox  we  find 
a  similar  situation.  While  an  outside  view  of  dementia 
praecox  reveals  an  arbitrary  array  of  manifestations:  of 
delusions,  hallucinations,  queer  notions,  or  autochthonous 
ideas,  an  emotional  condition  often  out  of  harmony  with 
what  the  patient  says,  peculiar  incoherent  utterances  which 
impress  one  merely  as  a  scattered  ideation,  bizarre  acts 
often  executed  with  an  impulsiveness  which  appears  strik- 
ingly forced  and  elementary  —  an  analysis  often  shows  us 
that  instead  of  there  being  a  lack  of  connection  or  significance 
in  this  array  of  manifestations,  all  these  expressions  mean 
something  to  the  patient,  that  definite  principles  of  depen- 

t  See  Hoch,  A.  Constitutional  Factors  in  the  Dementia  Praecox  Group. 
Review  of  Neurology  and  Psychiatry,  August,  1910. 

X  Bimbaum.  Psychosen  mit  Wahnbildung  und  wahnhafte  Einbilduogea 
be!  Degenerativen.     Carl  Marhold,  Halle,  1908. 


54  Dementia  Praecox 

dence  of  the  individual  symptoms  upon  each  other  can  be 
made  out,  that  certain  mechanisms  are  at  work,  and  that 
instead  of  an  arbitrary  diffusion  there  is  in  these  manifes- 
tations a  certain  limitation  to  definite  trends.  There  are 
cases,  therefore,  in  which  the  same  principles  exist  as  in 
some  paranoic  states  and  in  some  degenerative  psychoses. 
The  question  is  only  how  general  an  application  may  we 
claim  for  this.  It  is  not  easy  to  analyze  cases  of  dementia 
praecox,  and  a  satisfactory  demonstration  has  been  possible 
in  a  limited  number  of  instances  only,  yet  aside  from  those 
we  have  many  examples  in  which  more  or  less  clear  indica- 
tions point  in  the  same  direction,  to  say  nothing  of  the  sup- 
port which  such  a  view  receives  from  other  sources,  namely 
from  the  general  principles  as  claimed  by  Dr.  Meyer,  and 
from  the  recognition  of  constitutional  deficiencies  which 
forms  an  integral  part  of  these  principles.  On  the  other 
hand,  it  must  be  frankly  admitted  that  there  are  still  many 
gaps,  and  that  a  growing  knowledge  of  the  clinical  pictures, 
with  perhaps  a  clearer  separation  of  cases  into  smaller 
groups,  may  also  demonstrate  that  mechanisms  of  another 
sort  are  at  work.  The  reason  the  situation  is  clearer  in 
some  paranoic  and  degenerative  psychoses,  and  why,  there- 
fore, in  them  the  psychogenic  origin  is  not  doubted,  is 
because  there  the  conflicts  are  on  the  surface,  they  often  lie 
essentially  in  an  external  situation,  whereas  in  dementia 
praecox  the  external  factors  are  insignificant  compared  with 
the  internal  conflicts.  We  are,  therefore,  in  dementia 
praecox  dealing  with  undercurrents,  which,  however,  as  our 
experience  shows,  seem  to  give  rise  to  the  same  sort  of 
attempts  at  adjustment  as  those  conflicts  which  are  more 
on  the  surface,  but  they  are  often  less  transparent,  the  con- 
flicts less  obvious,  partly  because  the  normal  person  cannot 
understand  the  opposing  forces  of  the  conflicts  and  the  real 
desires,  partly  because  they  refer  to  very  personal  matters, 
and  therefore  are  under  the  influence  of  distorting  and  re- 
pressing forces  which  make  the  analysis  more  difficult. 
Any  one  who  has  analyzed  cases  of  dementia  praecox  must 
have  been  impressed  with  the  fact  that  the  content  often 
unmistakably  refers  to  disharmonies  in  the  sexual  sphere, 
and  this  is,  as  we  have  reason  to  believe,  not  accidental, 


Somf  Mental  Mechanisms  in  Dementia  Praecox    55 

but  due  to  a  fundamental  defect  of  sexual  adaptation  in  its 
widest  sense. 

I  need  hardly  say  in  this  audience  that  it  is  essentially 
Freud  and  Jung  to  whom  we  owe  our  insight  into  these 
principles,  which  are  at  times  more  clearly  in  evidence  in 
dementia  praecox  than  in  hysteria,  though  not  fundamen- 
tally different  from  those  of  the  neuroses  and  of  every-day 
life.  I  propose  to  take  up  the  subject  by  giving:  (1)  the 
analysis  of  a  case  who  evidentally,  owing  to  the  compara- 
tively good  mental  makeup,  was  particularly  accessible, 
and  who,  probably  for  the  same  reason,  eventually  recov- 
ered; (2)  the  analysis  of  another  case  who  did  not  recover; 
and  (3)  a  brief  general  description  of  some  of  the  more 
obvious  mechanisms  with  which  we  are  as  yet  acquainted, 
without  any  claim  to  completeness,  even  so  far  as  our  pres- 
ent knowledge  goes. 

The  first  case  is  that  of  a  young  girl  of  seventeen,  who 
when  seen  presented  a  certain  amount  of  excitement;  yet 
without  real  distress,  she  tried  the  doors,  made  peculiar 
statements.  She  said  that  some  one  was  in  distress,  that 
the  country  was  in  trouble,  that  she  was  "the  center  of  a 
good  deal."  She  spoke  of  explosions  and  automobile  acci- 
dents, of  fires,  and  the  like, —  events  of  which  she  had 
learned  from  headlines  in  the  newspapers  which  were  lying 
about;  but  she  did  not  blame  herself  for  it,  as  melan- 
cholies would.  She  spoke  of  electricity  being  applied  to  her, 
said  that  she  felt  connected  in  some  way;  she  heard  voices 
which  said,  "Stand  still,"  "Get  up,"  "Lookout,"  "Danger." 
She  suddenly  saw  "a  fog"  and  in  it  a  railroad  train  and  a 
face.  She  often  would  not  go  to  bed,  and,  without  being 
able  to  explain  it,  would  violently  oppose  any  attempt  at 
putting  her  to  bed.  At  other  times  she  would  not  eat, 
would  not  pass  her  urine,  was  very  insistent  that  some 
special  patients  in  the  ward  should  not  be  there.  She  often 
asked  what  things  meant,  in  fact  to  anything  which  was  at 
all  obtrusive  a  feeling  of  self-reference  was  attached.  She 
slept  poorly  and  ate  insufficiently.  She  was  always  ori- 
ented as  to  her  surroundings.  The  patient  presented, 
therefore,  a  peculiar  impulsive  behavior,  which  was  never 
accounted  for  by  the  situation,  nor  by  any  obvious  ideas; 


56  Dementia  Praecox 

a  markedly  negativistic  attitude  at  times,  hallucinations  in 
the  form  of  voices,  electricity,  and  occasionally  visions;  ideas 
of  reference,  odd  acts,  the  whole  characterized  by  a  peculiar 
lack  of  transparency  and  want  of  connection. 

The  anamnesis  told  us  that  the  patient  had  been  self- 
willed,  pedantic,  with  a  great  desire  for  consistency  and  jus- 
tice; she  was  ashamed  of  her  menstruation,  but  withal  fairly 
natural.     At  six  a  boy  had  intercourse  with  her,  and  threat- 
ened her  if  she  told  about  it.     She  claims  she  did  not  think 
niuch  of  it.     At  about  the  age  of  ten  she  began  to  mastur- 
bate and  worried  much  about  this.     When  eleven,  she  one 
morning  woke  up  frightened  and  saw  Christ  on  the  cross. 
The  night  before  she  had  sat  at  the  window  listening  to 
men  who  went  by,  wondering  who  they  were  and  whether 
she  would  ever  meet  them.     She  does  not  remember  any 
other  fancies  at  the  time.     In  the  morning  after  the  vision 
she  worried  about  her  masturbation,  and  then  the  episode 
at  the  age  of  six  came  to  her  mind  and  she  confessed  it  to 
her  grandmother.    When  thirteen  and  fourteen  she  used  to 
sit  more  often  at  the  window  at  night,  losing  much  sleep 
thereby,  dreaming  in  the  same  way  as  when  she  was  eleven. 
It  is  probable  —  but  we  can  only  infer  it  —  that  sexual 
fancies  occurred  at  that  time.     She  worked  normally  until 
fifteen,  when  she  became  absorbed,  could  not  do  her  work, 
and  half  a  year  later  dropped  it  all.      She  was  sent  to  a 
relative,  the  place  where  she  had  lived  when  six;  she  became 
worse,  surprised  her  people  by  saying  that  she  was  in  love 
with  a  man  whom  she  scarcely  knew;  she  kept  watching  the 
house  of  a  physician  whom  she  also  knew  but  superficially, 
thought  of  him  a  good  deal,  as  she  confessed  later;    she 
claimed  she  saw  another  man,  whom  she  had  seen  at  her 
own  home,  pass  daily  on  a  train,  saying  she  recognized  him 
only  by  his  hat.     When  again  at  home,  near  the  sea,  she 
saw  searchlights,   and    thought    the    doctor    above    men- 
tioned was  "in  distress,"  saw  a  vapor  with  his  face  in  it. 
When  taken  to  her  family  doctor  there  were  two  men  in  his 
waiting  room;  she  thought  they  were  there  to  tell  the  doctor 
of  her  masturbation,  or  about  her  love  for  the  other  physi- 
cian; she  also  felt  that  one  of  the  men  was  exerting  electrical 
influences  upon  her.     In  a  shoe  store  she  thought  she  re- 


Some  Mental  Mechanisms  in  Dementia  Praecox     57 

cognized  the  man  who  passed  on  the  train,  and  the  shoes  she 
bought  she  never  could  wear  because  they  were  "charged 
with  electricity."  Finally,  when  she  was  again  sent  to  the 
same  relatives,  she  at  once  became  more  markedly  abnormal, 
spoke  of  wires  being  through  the  house,  of  being  surrounded 
by  electricity,  she  refused  food,  hesitated  to  pass  her  urine, 
wanted  things  "straightened  out,"  was  undecided,  and 
suddenly  claimed  she  was  married. 

This  patient  could  be  analyzed  even  during  the  active 
stage  of  her  condition,  as  it  was  found  that  she  always  quieted 
down  when  this  was  done.  In  the  analysis  many  of  the  facts 
which  have  been  embodied  in  the  history  were  obtained, 
as  well  as  the  following: 

It  became  clear  that  the  idea  of  electricity  repre- 
sented a  very  important  part  of  the  picture  and  furnished 
the  key  to  the  situation.  She  said  that  electricity  was  tried 
in  a  way  that  it  should  not  be  tried,  and  said  in  the  same 
connection  that  some  one  was  trying  to  be  near  her,  and 
finally  that  different  people  were  trying  to  marry  her,  or 
were  trying  something  which  she  did  not  wish  to  have  tried. 
At  last  it  was  found  that  the  electricity  was  localized  in  her 
sexual  organs,  and  that  the  sensations  were  quite  unlike 
electricity,  but  like  the  feeling  which  she  had  perceived  during 
the  sexual  traumatism  in  the  sixth  year.  This  explained, 
then,  the  meaning  of  these  sensations.  And  then  the  idea 
that  she  felt  the  electricity  in  the  shoe  store,  and  that  the 
shoes  were  later  charged  with  electricity,  also  became  com- 
prehensible. Moreover,  it  was  found  that  these  sexual 
sensations  increased  when  she  remained  in  certain  positions 
for  any  length  of  time;  hence  she  heard  warning  voices, 
saying  "  Stand  up,"  "  Look  out " ;  they  were  most  pronounced 
in  bed;  hence  she  frequently  refused  to  go  to  bed,  fought 
desperately  when  put  there.  The  reason  why  she  objected 
to  the  presence  of  certain  patients  became  clear  when  it 
was  found  that  all  these  were  patients  who  wet  their  bed; 
that  this,  as  she  said,  suggested  to  her  kidney  disease;  the 
latter  in  turn  suggested  a  vaginal  examination,  which  her 
family  physician  had  made,  and  this  led,  therefore,  directly 
to  the  main  trend.  The  refusal  of  food  found  its  explana- 
tion partly  in  the  fact  that  the  sensations  increased  after 


58  Dementia  Praecox 

eating,  partly  in  that  she  had  heard  her  family  physician 
say  at  one  time  that  meat  increased  the  sexual  desire. 
The  voices,  the  idea  that  some  one  was  in  distress,  etc., 
were  invariably  traced  to  one  of  the  men  mentioned  in  the 
history,  and  were  probably  also  determined  by  a  projection 
of  her  own  distress. 

I  think,  therefore,  that  the  case  resolves  itself  into 
this:  we  have  here  a  girl  who  had  an  early  concrete  sexual 
experience.  This  very  probably  led  her  thoughts  into  the 
direction  of  sexual  matters  to  a  degree  which  evidently  went 
beyond  the  normal  tendencies  of  this  sort  —  and  more 
Important  to  note  is  the  fact  that  certain  reactions  all  along 
showed  that  these  fancies  were  evidently  disturbing  factors. 
She  lost  sleep  sitting  at  the  window  wondering  who  the 
men  were  who  went  by,  whether  she  would  meet  them,  etc. ; 
in  this  connection  It  is  Interesting  that  immediately  after 
the  first  episode  of  this  kind  she  woke  up  with  fright  and 
had  a  religious  vision,  and  then  worried  about  her  mastur- 
bation and  her  earlier  experience  with  the  boy.  Then  the  fact 
that  she  was  ashamed  of  her  menstruation  is  of  Interest,  and 
her  growing  pedantry,  her  desire  to  have  things  right,  may 
have  been,  as  It  often  Is,  a  reaction  to  the  feeling  of  guilt 
about  sexual  ruminations. 

Finally,  there  came  an  absorbed  period  which  was  so 
marked  that  any  objective  Interest  and  activity  became 
Impossible.  And  then  came  that  peculiar  diffuse  rather 
than  specific  application  of  her  love  to  real  persons,  as  is 
the  case  so  frequently  In  dementia  praecox,  and  which  In 
itself  points  to  the  marked  lack  of  sexual  adaptation.  She 
said  she  was  In  love  with  several  men  whom  she  merely 
knew  from  a  distance,  and  thought  she  saw  them  in  various 
places. 

Now  It  Is  very  natural  that  the  original  and  only  sexual 
experience  played  a  part  In  her  fancies,  and  when  these 
became  dominant  the  sensations  connected  with  It  were 
represented  by  hallucinations;  this  was  then  a  wish-fulfil- 
ment; but  with  it  came  something  like  a  compensation, 
something  like  a  feeling  of  guilt  arose  and  she  became  stirred 
up,  substituted  electricity  for  sexual  sensations,  and  the 
twhole  picture  was  then  made  up  of  these  sensations, —  of  a 


Some  Mental  Mechanisms  in  Dementia  Praecox     59 

certain  excitement,  a  feeling  of  danger  with  warning  voices, 
the  ideas  of  reference,  the  shunning  of  anything  which  re- 
called the  main  trend.  In  other  words,  the  symptoms  were 
largely  grouped  around  the  electrical  sensations,  while 
others,  such  as  the  hallucinations,  "I  love  you,"  the  seeing 
of  the  men,  the  appearance  of  the  fog  with  the  railroad 
train,  the  face,  and  the  like,  were  phenomena  parallel  to  the 
sexual  sensations,  but  probably  because  they  were  not  of 
such  a  disturbing  character  they  remained  comparatively  in 
the  background. 

The  second  case  is  a  woman  thirty-six  years  of  age,  who 
even  as  a  child  was  sensitive  and  stubborn;  she  often  left 
the  table  on  slight  provocation,  was  hard  to  guide  and  in- 
fluence, and  was  not  inclined  to  confide  in  any  one.  She  had 
a  certain  tendency  to  romanticism;  liked  literature  and  music, 
without,  however,  having  any  knowledge  of  either  sufficient 
to  give  her  a  deep  interest  in  them.  Before  her  marriage  her 
brother  took  her  into  his  business  as  an  assistant  in  the 
office,  but  she  was  inefficient,  and  yet  constantly  objected 
that  she  was  not  given  better  work  to  do.  When  twenty  she 
married  a  cousin  who  was  disliked  by  the  family,  and  whom, 
it  is  thought,  she  herself  really  did  not  love.  As  a  matter  of 
fact  she  never  got  along  well  with  him,  and  as  marked  evi- 
dence of  this  there  stand  out  the  following  prominent  fea- 
tures. In  the  first  place  she  always  made  demands  upon 
him  which  she  knew  he  could  not  fulfill  with  his  means; 
thus  she  wanted  him  to  get  a  horse  and  carriage,  and  matters 
of  that  sort.  It  was  not  long  after  the  marriage  that 
another  trait  appeared  which  we  also  have  reason  to  regard 
as  a  serious  lack  of  adaptation,  namely,  her  jealousy  of  him. 
This  came  out  for  the  first  time  plainly  during  her  first 
childbirth,  when  she  suspected  her  husband  of  being  in  love 
with  her  nurse.  Four  years  after  her  marriage  she  met  a 
dentist  who  called  her  Miss  instead  of  Mrs.;  she  did  not 
correct  him.  He  made  a  deep  impression  upon  her,  she  felt 
that  he  was  different  from  her  husband,  more  sympathetic, 
that  she  could  talk  better  to  him;  she  became  infatuated 
with  him  at  the  time,  as  she  herself  said  later.  She  had 
another  child,  and  the  same  nurse  took  care  of  her.  She 
again  got  the  idea  that  her  husband  was  in  love  with  this 


60  Dementia  Praecox 

nurse.  Nine  years  after  marriage,  five  years  after  she  met 
the  dentist,  she  was  pregnant  with  the  third  child,  Mary.  In 
the  mean  time  the  lack  of  adaptation  to  lier  husband  had 
increased,  and  her  affection  for  the  dentist  had  become  more 
marked,  so  much  so  that  at  that  time,  as  was  discovered 
later,  she  had  various  longings  which  were  to  play  an  im- 
portant part  in  her  psychosis.  Her  relations  towards  her 
husband  did  not  improve,  there  were  frequent  scenes,  and 
she  continued  to  be  suspicious  of  him,  in  regard  not  only  to 
the  nurse,  but  also  to  some  other  woman.  For  some  years 
before  the  onset  of  the  psychosis  they  had  very  little  sexual 
relation  with  each  other,  and  for  three  years  it  had  been 
given  up  entirely. 

In  the  fall  of  1906  she  suspected  her  husband  of  intimacy 
with  an  Italian  girl  who  occasionally  visited  his  shop,  and 
when,  in  January,  1907,  she  saw  this  girl  deposit  some  money 
in  a  bank  she  took  this  as  a  confirmatory  evidence  that  her 
husband  was  intimate  with  her. 

In  June,  1907,  she  was  invited  to  stay  at  her  sister's 
house,  while  the  latter  was  absent.  There  she  read  two 
books  which  made  a  considerable  impression  on  her, 
because  they  seemed  to  her  to  fit  her  case;  one  was  about  a 
woman  whose  husband  was  unkind  to  her  and  gave  her  no 
money,  who  consequently  thought  of  leaving  him,  but  who, 
as  the  patient  put  it,  remained  at  her  post  and  died;  she 
had  a  devoted  friend  who  was  true  to  her  to  the  end.  In 
another  story  she  read  of  a  man  who  lived  a  life  of  self- 
denial  to  serve  the  woman  he  loved,  but  whom  he  could  not 
marry.  She  thought  of  herself  as  the  heroine  and  of  the 
dentist  as  the  hero.  Towards  the  end  of  June,  and  probably 
not  by  accident,  she  one  Thursday  went  to  see  the  dentist, 
and  then  while  sitting  in  his  chair  a  feeling  of  love  came  over 
her.  It  returned  again  at  night,  and  then  for  a  while  every 
night,  after  she  had  gone  to  bed,  and  she  masturbated 
repeatedly.  Then  it  returned  with  special  force,  chiefly 
every  Thursday  night,  and  then  the  more  marked  symptoms 
of  the  psychosis  arose.  She  began  to  feel  the  dentist's 
presence  near  her,  and  a  feeling  came  over  her  as  if  she  were 
again  looking  into  his  eyes,  "a  feeling  of  love  and  longing, 
a  sensuous  feeling,"  as  she  herself  expressed  it.     She  used  to 


Some  Mental  Mechanisms  in  Dementia  Praecox     61 

sit  on  the  porch  at  night  and  sing  all  the  love  songs  she  knew. 
They  came  without  effort.  As  this  went  on  she  could  not 
put  her  mind  on  her  work.  In  regard  to  this  period  the 
husband  says  that  he  noticed  nothing  except  that  she  lay 
down  a  good  deal,  was  somewhat  absorbed,  and  once  he 
heard  her  talk  to  herself.  By  the  end  of  August  paranoic 
ideas  regarding  her  husband  again  appeared;  she  found 
a  stopcock  on  the  gas  stove  turned  on,  and  suspected  that 
her  husband  wanted  to  kill  her  and  the  children;  she  also 
believed  he  had  put  something  into  the  oatmeal  for  the  same 
purpose;  she  was  not  sure  whether  her  husband  had  done 
this  himself  or  whether  an  Italian  had  done  it  for  him. 
Nothing  further  was  noticed  by  her  friends  until  September 
lo,  when  she  suddenly  proposed  to  go  to  California  to  visit 
her  sister.  In  talking  of  this  during  the  analysis  she  said 
that  she  thought  getting  away  would  help  her  to  overcome  the 
feeling  for  the  dentist  which  had  taken  such  a  hold  of  her. 
This  plan  was  refused,  but  she  repeated  the  same  proposal 
a  few  days  later,  and  at  the  same  time  made  an  attempt  to 
again  straighten  out  her  relationship  to  her  husband.  She  con- 
fessed to  him  that  she  had  been  in  love  with  the  dentist  for 
thirteen  years,  and  asked  him  for  forgiveness.  He  rebuked 
her,  and  he,  as  well  as  the  other  members  of  the  family,  said 
it  was  too  expensive  to  go  to  California.  Next  day  the  con- 
dition changed.  She  said  that  she  was  "in  a  muddle"; 
began  to  talk  in  a  disconnected  manner  of  things  which 
were  not  understood  by  those  about  her.  What  Is  remem- 
bered of  It  is  the  following:  she  spoke  of  having  kissed  the 
old  family  doctor,  of  white  pills  which  he  had  given  her;  she 
thought  somehow  some  harm  was  done;  she  spoke  of  a  murder 
committed  by  an  Italian  years  before.  She  became  reli- 
gious, said  she  wanted  to  do  what  was  right,  wanted  to  bring 
all  together  and  take  them  to  church;  she  spoke.  In  this  con- 
nection quite  Irrelevantly,  of  gauze  shirts,  thought  the  den- 
tist was  one  Alexander,  a  former  friend  of  the  family;  again 
thought  she  saw  the  dentist  In  various  other  persons. 

When  first  observed  the  patient  appeared  oriented, 
but  later  said  for  a  time  she  thought  she  was  among  the  Blue 
Alsatian  Mountains.  She  was  nervous,  uneasy,  anxious  to 
talk.     She  said  at  once,  quite  Irrelevantly,  that  her  family 


62  Dementia  Praecox 

physician  had  given  her  large  white  pills  during  her  child- 
birth; she  made  other  remarks  about  the  subject  of  child- 
birth, not  only  of  her  own,  but  also  of  that  of  her  sister,  and 
when  asked  why  she  said  all  these  things,  she  answered,  "It 
seems  to  be  in  my  mind  as  though  there  was  some  connection." 
When  questioned  what  this  connection  was,  she  said  that 
the  doctor  also  took  care  of  her  husband  while  he  had  appen- 
dicitis, that  he  told  her  he  could  not  say  what  the  outcome 
would  be,  and,  after  the  husband  was  saved,  he  asked  her 
to  kiss  him;  she  added:  "The  thought  comes  to  me  that 
the  baby  resembled  the  nurse  who  took  care  of  him  —  is 
such  a  thing  possible?"  When  told  that  this  was  nonsense, 
she  said,  "But  why  does  the  thought  come  to  me?" 
During  the  rest  of  the  day  she  became  more  excited,  kept 
breathing  very  deeply,  would  not  keep  on  any  clothes, 
slapped  herself  vigorously,  and  became  very  forced  in  her 
attempts  at  breathing. 

Next  day  she  said  that  she  felt  forced  to  breathe 
deeper  and  deeper,  that  she  could  not  stop,  that  a  feeling 
came  over  her  as  if  she  were  paralyzed,  and  that  she  had  to 
slap  herself;  again  she  said  that  she  could  not  move  her 
hands  from  her  side  and  felt  like  a  post.  She  also  spoke  of 
having  heard  people  talk  about  a  court,  said  she  was  afraid 
Mary  was  dead,  "Perhaps  some  one  might  have  given  her 
something  wrong."  In  answer  to  the  question  why  she  was 
so  uneasy,  she  said  that  she  ought  to  have  told  her  husband 
about  her  sensations  which  she  had  at  the  dentist's,  yet  when 
asked  what  sensations,  she  mentioned  a  toothache. 

On  the  third  day  she  became  more  quiet  and  rational, 
and  remained  so  for  two  weeks;  various  symptoms  were 
present,  certain  ideas  of  reference,  a  certain  uneasiness  about 
the  court.  The  latter  she  associated  with  the  dentist. 
Perhaps  he  might  have  given  her  child  something  which 
harmed  her  and  he  might  now  be  prosecuted  by  the  law;  she 
spoke  of  the  dentist  testing  her  in  some  way.  Above  all 
there  was  present  a  constant  desire  to  see  her  children, 
especially  Mary.  She  repeatedly  thought  the  children  were 
in  the  next  house  and  tried  to  get  to  them;  she  often  tried  to 
run  away  and  could  in  no  way  be  reasoned  with  regarding 
this  desire  to  see  her  children.     The  idea  came  to  her  that 


Some  Mental  Mechanisms  in  Dementia  Praecox     63 

perhaps  in  some  way  she  might  have  harmed  the  old  family- 
doctor.  Then  another  excitement  appeared,  but  without 
such  markedly  forced  or  odd  actions.  It  seemed  merely 
to  be  a  constant  senseless  desire  to  get  away  to  her  children, 
with  violent  attacks  upon  the  nurses  when  they  would  not 
open  the  doors,  and,  associated  with  this,  was  a  constant 
insistence  on  following  the  examiner  whom  she  finally  half 
identified  with  the  dentist,  or  called  by  the  name  of  her 
husband.  After  six  or  seven  days  she  again  quieted  down, 
but  was  no  longer  accessible  for  further  analysis.  One  could 
not  get  beyond  such  statements  as  that  she  was  nervous 
because  she  wanted  to  see  her  children  and  the  like.  She 
was  then  taken  home  by  her  family,  having,  so  far  as  could 
be  ascertained,  no  definite  delusions  at  that  time.  At  home 
she  took,  quite  contrary  to  her  usual  habit,  exceptionally 
good  care  of  the  household,  but  at  the  same  time  dressed 
with  great  care,  bought  clothes  beyond  her  means,  sur- 
prised the  family  by  denying  that  she  had  been  in  a  hospital 
and  by  denying  that  the  house  had  been  sold  to  her  brother. 
The  latter  had  been  done  in  order  to  raise  some  money, 
and  the  patient  herself  had  attached  her  signature  to  the 
deed.  After  a  month  at  home  the  patient  was  sent  on  a  trip 
to  California  to  visit  a  sister,  accompanied  by  her  brother. 
While  she  did  fairly  well  at  first,  her  condition  soon  became 
worse  and  she  had  to  be  sent  to  a  hospital  in  California, 
where  she  still  is  a  patient,  nearly  three  years  after  the  onset. 
While  we  have  thus  far  become  acquainted  with  the 
superficial  facts  of  the  psychosis,  we  shall  now  have  to  add 
the  results  of  the  analysis  and  the  interpretations  derived 
therefrom.  Here  again,  as  in  the  last  case,  a  special  set  of 
symptoms  gave  the  key  to  the  situation.  As  there  it  was  the 
electrical  sensations,  so  it  was  here  the  peculiar  breathing 
and  slapping,  etc.,  the  analysis  of  which  led  us  back  to  an 
occurrence  nine  years  before,  namely,  to  the  time  when  she 
was  pregnant  and  when  the  birth  of  her  daughter  Mary 
occurred.  Her  husband  was  ill  with  appendicitis  towards 
the  latter  part  of  her  pregnancy,  and  as  the  relationship 
between  the  two  at  the  time  was  strained  and  her  longing 
for  the  dentist  again  had  swept  over  her,  she  wished  that  he 
might  not  recover,  when  the  family  physician  told  her  that 


64  Dementia  Praecox 

he  was  In  danger.  She  felt  that  then  her  chances  for  marry- 
ing the  dentist  would  be  better;  that  the  dentist  was  already 
married  throws  an  interesting  light  upon  her  personality, 
upon  the  lack  of  adaptation  of  her  desires  to  reality,  or  per- 
haps upon  that  peculiar  inadequate  way  in  which  dementia 
prsECox  personalities  apply  their  libido.  The  husband  got 
well,  and  when  he  was  out  of  danger  the  old  family  phy- 
sician asked  her  to  kiss  him  for  having  saved  him.  Then 
the  childbirth  came  and  a  similar  train  of  thought  occurred. 
She  hoped  the  child  would  not  be  born  alive,  because  her 
chances  for  marrying  the  dentist  would  be  less  with  three 
than  with  two  children.  The  physician  told  her  that  there 
was  some  danger  and  that  her  pains  were  inadequate,  and 
that  it  was  necessary  for  her  to  exert  herself,  to  bear  down,  to 
breathe  deeply,  and  he  gave  her  white  quinine  pills  to  in- 
crease her  labor  pains.  She  did  not  follow  his  directions 
adequately,  as  they  did  not  meet  with  her  own  desire,  but 
the  child  was  born  and  grew  up  a  healthy  girl. 

The  elements  of  this  episode  which  are  here  put  to- 
gether in  a  connected  story  we  find  again  in  a  disconnected 
manner  in  her  psychosis.  This  episode  may  well  have 
stood  in  her  mind  as  the  symbol  of  her  desire  to  get  away 
from  the  husband  and  to  marry  the  dentist. 

After  she  had  for  several  years  virtually  broken  off 
her  relationship  with  her  husband  and  was  beginning  again 
to  apply  her  love  to  some  one  else,  it  was  this  older  part  of 
the  same  trend  which  again  came  up;  she  was  now  compen- 
sating for  her  lack  of  exertion  at  the  time,  with  the  forced 
straining,  slapping,  beating  herself,  etc.;  yet  the  opposite 
was  not  lacking,  she  feared  that  Mary  might  be  dead.  We 
know  now  that  such  fears  represent  very  often  repressed 
wishes.  So  that  again  there  was  on  the  one  hand  the  asser- 
tion of  her  desire  to  have  the  child  dead,  and  on  the  other 
hand  a  compensation  for  this  desire.  It  is  not  improbable 
that  the  feeling  which  at  times  came  over  her,  namely,  that 
in  spite  of  the  slapping  and  breathing  there  was  something 
like  a  paralysis,  may  have  stood  as  a  symbol  for  the  child's 
death,  just  as  at  the  time  of  the  birth  the  lack  of  exertion 
stood  for  it.  Of  a  similar  nature  is  possibly  her  thought 
that  Mary  looked  like  the  nurse,  in  other  words,  was  not  her 


Some  Mental  Mechanisms  in  Dementia  Praecox    65 

child.  Her  speaking  irrelevantly  about  an  actual  murder 
in  the  neighborhood  by  an  Italian  some  years  ago  probably 
had  some  connection  with  her  husband,  whom  she  suspected 
of  being  in  love  with  an  Italian  girl.  It  must  be  remem- 
bered that  later  she  suspected  her  husband  of  wishing  to 
kill  her  and  doing  it  through  an  Italian;  we  know  that  such 
suspicions  are  often  projected  wishes.  The  feeling  of 
guilt  in  regard  to  the  child  liberated  as  another  compensation 
the  idea  about  the  court,  which  was  quite  prominent  at 
times,  and  the  general  idea  that  some  wrong  had  been  done. 
It  is  certainly  interesting  that  she  projected  her  guilt  on  the 
dentist,  thought  that  perhaps  he  had  done  something  to 
Mary,  and  that  there  was  going  to  be  a  court  proceeding 
about  him.  Then  the  general  uneasiness  was  attributed,  not 
to  the  real  source,  but  to  such  trivial  substitutive  matters 
as  her  kissing  the  old  family  physician,  or  her  not  having 
told  her  husband  about  her  toothache.  The  Idea  that  the 
dentist  was  testing  her  in  some  way  may  have  been  a  part 
of  that  peculiar  paranoic  tendency  which  we  often  find  in 
such  cases  where  some  sort  of  a  relationship  is  Imagined, 
instead  of  the  desired  one,  often  of  a  persecutory  nature. 
Quite  clear  as  a  form  of  compensation  or  atonement  is  the 
patient's  constant  desire  to  see  her  children,  especially 
Mary,  which  became  at  times  very  insistent  and  impulsive 
and  dominated  the  clinical  picture  for  a  while.  Of  interest  Is 
also  the  delusion  about  Alexander.  This  Alexander  was  a 
childhood  love  of  the  patient.  She  said  that  she  had  often 
connected  the  two,  the  dentist  and  Alexander,  because  their 
eyes  were  so  much  alike,  and  it  Is  possible  that  she  fell  in 
love  with  the  dentist  because  of  this  fact.  When  asked  what 
satisfaction  It  could  possibly  give  to  her  to  identify  the 
dentist  with  Alexander,  she  said,  with  that  Insight  which 
we  find  at  times  in  our  analyses,  that  then  the  dentist  would 
not  be  married,  because  Alexander  was  not  married;  that 
she  later  connected  the  examiner  with  the  dentist  and  with 
her  husband  was  an  Instance  of  that  typical  diffuse  applica- 
tion of  the  libido  which  we  see  in  dementia  praecox  so  often. 
The  religiousness  which  was  present  in  the  early  part 
of  the  psychosis  is  a  frequent  form  of  compensation.  She 
wanted  to  go  to  church;  she  said  again  and  again  that  she 


66  Dementia  Praecox 

wanted  to  do  what  was  right;  she  wanted  to  take  others  to 
church,  spoke  of  wishing  to  unite  every  one,  all  of  which  is 
along  the  line  of  the  same  desire  for  a  moral  readjustment. 
It  was  at  this  time  that  a  peculiarly  irrelevant  utterance 
about  a  gauze  shirt  frequently  appeared.  When  the  patient 
was  probed  about  the  significance  of  gauze  shirts  it  was 
found  that  in  June  when  she  went  to  the  dentist  it  was  very 
hot  and  she  did  not  change  her  clothes,  more  especially  her 
gauze  shirt,  and  she  felt  that  the  dentist  might  perceive  an 
odor.  Why  this  came  out  at  the  time  I  do  not  know,  but 
it  is  clear  that  it  belongs  to  the  same  general  trend. 

If  we  now  summarize  this  case  we  find  that  we  have  a 
woman  who  was  somewhat  of  a  shut-in  personality,  inas- 
much as  she  was  not  easily  influenced  by  her  environment  and 
was  unable  to  adjust  herself  well.  Throughout  her  married 
life  there  was  a  marked  lack  of  adaptation  to  her  husband, 
showing  itself  in  demands  which  she  made  upon  him  and 
which  she  knew  he  could  not  fulfil,  but  also  in  her  jealousy  of 
him.  This  lack  of  adaptation  finally  found  its  expression 
in  the  cessation  of  intercourse.  Long  before  this  her  long- 
ing for  another  man  manifested  itself,  and  when  the  husband 
was  ill  she  wished  he  would  die,  and  when  her  childbirth 
occurred,  that  the  child  would  not  be  born,  so  that  her 
chances  to  marry  the  other  man  would  be  greater,  and  con- 
sequently she  refused  to  help  in  the  birth;  all  this,  in  face 
of  the  fact  that  the  other  man  was  married.  Later  there 
followed  some  years  of  a  virtual  separation  from  her  hus- 
band, during  which  there  was  no  other  outlet  for  her  interest, 
for  she  was  not  specially  fond  of  her  children,  and  had  not 
much  social  intercourse  with  any  one  else;  and  preceding 
the  outbreak  of  the  disease  there  was  a  period  of  inactivity 
and  day-dreaming.  During  this  period  she  went  to  see  the 
dentist  often,  fell  in  love  with  him,  her  day-dreaming  about 
him  increased,  and  then  more  marked  symptoms  appeared, 
namely,  the  semi-automatic  singing  of  love  songs,  the  feeling 
of  his  presence,  and  a  greater  absorption.  This  was  fol- 
lowed by  renewed  suspicions  of  her  husband,  she  thought 
he  wanted  to  kill  her.  After  this  we  find  an  Interesting 
effort  towards  a  frank  readjustment,  her  confessing  to  her 
husband,  an  attempt  at  making  up  with  him,  and  a  desire 


Some  Mental  Mechanisms  in  Dementia  Praecox     67 

to  get  away  from  the  dentist.  When  she  was  repulsed  in 
both  these  directions  there  was  almost  at  once  a  change, 
and  the  more  acute  breakdown  came  on,  in  which  the  picture 
was  no  longer  clear,  but  in  which  the  same  trend  prevailed, 
namely,  that  of  her  relationship  to  her  husband,  her  desire 
to  get  away  from  him,  to  have  fewer  children,  to  marry  the 
dentist,  but  in  the  foreground  were  the  compensatory  ele- 
ments, as  we  have  described  in  the  analysis.  The  individual 
symptoms  were:  disconnected  talk  and  incomprehensible 
actions,  her  speaking  of  white  pills,  of  childbirth,  of  the 
family  doctor,  of  having  hurt  him  by  kissing  him,  of  the 
court,  of  her  feeling  guilty  for  not  having  spoken  to  her 
husband  about  the  toothache,  her  fear  about  Mary's  life, 
her  constant  desire  to  see  her  children,  her  peculiar  actions 
of  breathing  and  slapping  herself,  as  well  as  her  feeling 
paralyzed,  her  ideas  that  the  dentist  was  testing  her,  that  he 
was  really  Alexander,  the  idea  that  the  dentist  may  have 
given  something  to  Mary  to  hurt  her,  then  her  irrelevant 
talk  of  gauze  shirts.  All  of  these  acts  and  ideas  which  ap- 
peared wholly  disconnected  and  fragmentary,  and  entirely 
unaccounted  for  by  anything  which  we  could  at  first  observe, 
belong  to  the  same  trend  of  ideas,  directly  connected 
with  the  sexual  life  in  which  there  had  existed  conflicts  for 
years  prior  to  the  onset  of  the  psychosis.  It  is  rather  inter- 
esting that  the  patient  herself  said  that  she  did  not  know 
what  her  ideas  meant,  but  had  a  feeling,  as  she  expressed  it 
in  the  analysis,  that  there  was  some  connection. 

We  may  now  supplement  the  report  of  these  cases  by  a 
description  and  summing  up  of  the  most  obvious  mental 
mechanisms  found  in  this  disorder. 

In  the  first  place  we  find  always  the  mechanism  of 
wish  fulfilment.  In  Case  I  this  existed  in  the  idea  of  the 
patient  that  she  was  married,  in  the  hallucination  of  sexual 
sensations,  and  in  the  voice  which  said,  "I  love  you,"  etc.; 
in  Case  II,  in  the  presence  of  the  dentist  which  the  patient 
felt,  in  the  identification  of  the  dentist  with  Alexander,  and 
in  the  idea  that  the  child  looked  like  the  nurse.  In  some 
instances  coitus  is  represented  in  hallucinations.  One 
patient  had  a  vision  of  her  own  marriage;  another  constantly 
heard  her  lover  call  "come";     a  third  patient  heard  that 


68  .  Dementia  Praecox 

the  wife  of  the  man  towards  whom  her  longings  went  was 
to  be  killed. 

Akin  to  this  mechanism  is  the  fact  that  many  patients 
see  the  object  of  their  longings  in  all  sorts  of  persons,  al- 
though this  may  have  a  somewhat  different  significance  as 
well.  A  very  excellent  example  of  a  complicated,  delirium- 
like wish  fulfilment  is  given  in  Jung's  article  on  the  content 
of  the  psychosis. 

On  the  other  hand,  Case  I  also  covered  up  her  wish 
fulfilment,  that  is  to  say  she  called  that  which  we  ultimately 
found  to  be  plain  sexual  sensations  "electrical  influences," 
and  she  not  only  used  that  term  metaphorically,  but  she 
dealt  with  them  as  such  and  believed  them  to  be  electrical. 
Here  we  see  at  work  a  force  different  from  the  wish  fulfilment, 
something  akin  to  a  feeling  of  guilt  and  a  desire  to  compen- 
sate for  it.  It  is  this  compensation  which  represents  another 
very  important  and  very  frequent  type  of  mechanism.  Quite 
often  the  compensation  is  in  the  direction  in  which  the 
normal  person  compensates  when  the  feeling  of  guilt  is  pres- 
ent, namely,  in  the  direction  of  religion.  In  milder  or  early 
cases  we  find  then  greater  interest  in  religion,  in  more  ad- 
vanced ones  persistent  praying,  or,  as  I  saw  in  one  instance, 
the  constant  stereotyped  repetition  of  a  part  of  the  Creed. 
Definite  delusions  which  have  this  origin  also  frequently  exist, 
the  patient  is  "the  only  one  free  from  original  sin,"  is  the 
"Virgin  Mary,"  "St.  Ann";  hears  God  say,  "You  are  my 
beloved  child,"  and  sees  herself  go  to  heaven.  One  patient, 
who  had  fallen  in  love  with  a  priest,  had  the  idea  of  a  peculiar 
mystical  union  of  the  priest,  her  husband,  and  Christ.  Such 
vague  ideas  are  not  rare.  It  is  quite  possible  that  a  conception 
of  compensation  which  involves  the  idea  of  guilt  is  not  always 
the  correct  formulation,  but  that  somehow  the  undoing  of 
that  which  a  part  of  the  personality  desires  may  have  its 
origin  in  an  opposing  force  which  cannot  be  thus  expressed, 
and  which  has  its  root  in  the  lack  of  sexual  adaptation  and 
the  peculiar  personality  in  general.  This  seems  to  be  the 
view  of  Jung  and  Abraham.  In  hysteria  similar  opposing 
forces  are  found,  but  there  it  seems  the  feeling  of  guilt  is 
more  often  a  definite  link  or  determining  factor. 

Something  akin  to  compensation  is  to  be  found  in  the 


Some  Mental  Mechanisms  in  Dementia  Praecox     69 

anxiety  or  uneasiness  which  we  sometimes  find  associated  with 
wish  fulfilment,  as  in  Case  I,  or  in  the  case  who  suddenly  got 
much  frightened  when  she  thought  her  husband  had  been 
killed  by  a  priest  after  she  had  fallen  in  love  with  a  priest. 
Or  in  Case  II,  who  was  stirred  up  by  the  idea  that  her 
child  might  be  dead. 

This  leads  us  over  to  a  type  of  compensation  which 
we  may  call  paranoid^  inasmuch  as  it  manifests  itself  in  ideas 
of  persecution.  Here  it  represents  the  direct  undoing,  as  it 
were,  of  the  fulfilment  of  the  wish.  This  is  the  case  where  we 
have  the  belief  in  the  love  of  a  certain  person,  and  at  the 
same  time  the  persecution  by  that  person.  A  girl  hears  a 
man  say  that  he  wants  to  marry  her,  but  also  that  he  wants 
to  shoot  her;  or  another  patient,  who  believes  that  a  man 
is  in  love  with  her,  also  insists  that  he  is  persecuting  her.  In 
such  instances  the  patients  are  apt  to  push  the  ideas  of  per- 
secution to  the  foreground,  and  we  only  find  later  that  the 
opposite  is  peculiarly  intermingled  with  it.  All  this  shows 
how  closely  delusions  of  persecution  may  be  related  to  wish 
fulfilments,  and  may  explain  some  purely  persecutory  ideas. 

We  might  speak  of  mechanism  of  atonement  as  another 
type  of  compensating  mechanisms;  as,  for  example,  in  the 
patient  who  had  been  sexually  excited  by  seeing  certain 
things,  and  who  later  had  a  persistent  impulse  to  dig  out  hei 
eyes;  or  in  the  more  complicated  instance  furnished  by 
Case  II,  where  the  patient  made  up  for  her  lack  of  exertion 
during  childbirth  by  vigorously  breathing  and  slapping 
herself. 

An  interesting  mechanism  which  leads  us  from  these 
compensations  to  that  which  is  called  the  negativistic 
mechanism  is  to  be  found  in  the  shunning  of  anything  which 
tends  to  bring  up  the  main  trend,  the  sort  of  thing  which 
Freud  has  illustrated  in  his  psychopathology  of  every-day  life. 
This  is  the  case,  for  example,  where  the  patient  refuses  to  pass 
her  urine,  to  sit  down,  to  eat,  or  go  to  bed,  because  all  this 
associated  in  her  mind  with  her  special  difficulties;  here  may 
also  be  mentioned  the  substitution  of  trivial  things  for  the 
important  ones,  as  is  the  case  when  our  second  patient 
blamed  herself  for  kissing  the  family  physician,  or  for  not 
having  spoken  to  her  husband  about  her  toothache. 


70  Dementia  Praecox 

We  must  further  mention  that  peculiar  rather  gross 
tendency  to  shut  out  the  environment  by  warding  off  any 
interference, —  that  which  is  called  negativism,  which  we 
may  see  in  a  more  active  form  when  the  pat  ent  may  en- 
tirely refuse  to  have  anything  to  do  with  the  examiner;  or 
which  accounts  for  the  persistent  closing  of  the  eyes,  the 
shutting  out  of  the  outside  world,  and  probably  to  a  con- 
siderable extent  for  the  marked  so-called  negativistic  stupor. 

We  must  finally  mention  in  this  connection  that  fre- 
quently symbols  are  used  very  much  as  in  dreams.  Much  of 
that  which  is  incomprehensible,  particularly  in  some  of  the 
advanced  cases,  is  due  to  the  fact  that  we  do  not  understand 
the  symbols,  as  has  been  so  well  illustrated  by  Jung  and 
Maeder. 

If  we  now  glance  over  the  entire  field  of  these  data  and 
attempt  to  see  their  significance  and  their  laws,  we  find  that 
these  laws  are  not  essentially  different  from  those  of  normal, 
mental  life. 

From  a  general  psychological  point  of  view  we  may  say 
that  all  our  memories  are  grouped,  as  it  were,  in  more  or  less 
extensive  and  more  or  less  circumscribed  complexes,  in  the 
formation  and  cohesion  of  which  special  interests  take  an 
important  part.  We  might,  perhaps,  more  correctly  call 
the  complexes  centers  of  attraction.  We  can  conceive  of 
the  mind,  therefore,  as  made  up  essentially  of  trends  of  in- 
terest. In  the  course  of  individual  development  certain  main 
tendencies  of  the  personality  develop,  which  then  take  the 
lead,  while  other  tendencies  become  repressed.  These  re- 
pressed trends  exert,  nevertheless,  a  marked  influence  on  the 
conscious  thought  and  activity,  as  Freud  has  shown,  but 
in  normal  life  they  do  so  mainly  through  the  fact  that  the 
energy  they  supply  is  led  into  profitable  channels.  Every 
trend  naturally  pushes  towards  a  realization  in  the  direction 
of  its  feelings.  If  this  is  in  harmony  with  the  main  tenden- 
cies of  the  personality  this  is  useful  and  represents  the  dyna- 
mic force  behind  our  thinking,  and  our  pursu  ts  adapted  to 
the  environment  and  the  given  situation.  If,  however, 
trends  which  are  not  in  harmony  with  the  main  tendencies 
of  the  personality,  and  which  are,  therefore,  under  the  in- 
fluence of  repression,  no  longer  find  an  outlet  in  profitable 


Some  Mental  Mechanisms  in  Dementia  Praecox     71 

channels,  but  assume  a  more  or  less  Independent  dominating 
role,  it  is  not  to  be  supposed  that  the  laws  which  govern 
normal  mental  activity  should  be  suspended;  on  the  con- 
trary, we  shall  expect  to  find  the  same  principle  of  the  trend 
pushing  towards  its  realization,  while  at  the  same  time  the 
other  tendencies  of  the  personality  assert  themselves  in  re- 
pressing influences  as  well  as  in  adjustment  reactions,  but 
owing  to  the  disturbance  of  balance  between  the  usurping 
trend  and  the  main  tendencies  of  the  personality,  the  think- 
ing and  acting  is  then  no  longer  adapted  to  the  actual 
situation,  but  appears  as  something  strik  ngly  out  of  con- 
tact with  it,  and  is  of  a  simpler  and  cruder  type. 

This,  in  so  far  as  the  mental  side  is  concerned,  is  what 
seems  to  take  place  in  the  cases  of  dementia  praecox,  which 
can  be  analyzed;  the  overgrowth  of  certain  trends  at  the 
expense  of  the  main,  well-adapted  interests  of  the  personality. 


Re 


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